Compliance status (Executive Summary)

Any organization can benefit from effective communication. Poor communication within the healthcare industry contributes to operational inefficiencies and organizations’ failure to achieve their predetermined goals and objectives (Campbell, 2011). Given the multiple communication issues it encounters, it is clear from the audit report that Nightingale Community Hospital scarcely adheres to the Joint Commission criteria. First and foremost, the firm’s operations are significantly impacted by inconsistent reporting of crucial data within the allotted 60 minutes. Challenges of variations in the verbal order and read back audits are also evident, and this implies that cases of misreporting and interpretation of information are on a high within the health facility. The use of unacceptable abbreviations within the full year as provided in the report stood at 99.6%, a lack of compliance to set regulations by the Joint Commission. Application of the wrong abbreviation places the Nightingale Community Hospital because it may end up leading to misguiding information on prescriptions that may end up having negative effects on the patients. In some cases, there were instances of poor organizational communication among workers and this ends up impairing the firm’s quest for meeting its set goals. Based on the audit report, it is a high time that the leadership of hospital came up with suitable measures aimed at addressing the communication challenges that are in place.

Corrective action plans that will comply with Join Commission

In the quest for dealing with the communication challenges that are in place within the Nightingale Community Hospital, there are various measures that can be embraced. Firstly, the organization will have to come up with a training program where all the workers will be educated on effective communication and the benefits that come along with the strategy. The program will entail modes of employee-patient communications, reporting of information and horizontal communication among workers. All the employees in the hospital will be included in the entire training program on matters regarding communication improvement and thus an enhancement in workplace relations (Campbell, 2011). Only those medical abbreviations that are allowed by the Joint Commission will be embraced within the organization, and this will help in the reduction of errors that come along with the use of inappropriate abbreviations. Departmental managers will be required to conduct regular meeting with their employees, interact, update them on the various progress made by the firm. The employees, on the other hand, will be required to raise their grievances and make suggestions on the measures that the organization can embrace in bolstering its communication. Only those qualified physicians and Nurse Practitioners will be required to make prescriptions and provide medical advice to the patients. Apparently, this will help in the reduction of errors that occur during prescriptions and patient misinformation that have been experienced within the firm in the recent past.

Justification of the review area

Communication is an integral aspect of the Nightingale Community Hospital. It is through communication that workers can coordinate and collaborate in meeting the set goals and objectives. Poor communication contributes to operational inefficiencies that contribute to a decline in the firm’s productivity. Errors in prescriptions and poor oral and written medical advice primarily occurs when an organization lacks set communication strategies. In return, this ends up leading to a reduction in the patient demand and admission rates, thus decline in its revenue generations. The move by the Nightingale Community Hospital to come up with communication measures that are aligned with the Joint Commission Standards and regulations will be beneficial to the firm in various ways. First and foremost, satisfaction rates among the patients will improve significantly. Workplace relations will also be enhanced followed by a boost in the employee productivity and job satisfaction levels (Campbell, 2011). Finally, with improved communication, the hospital will also gain a competitive advantage over its rivals in the market.

References

Campbell, P. (2011). Nursing Management: Principles and Practice – Second editionNursing Management: Principles and Practice – Second edition. Nursing Standard, 26(12), 30-30. doi:10.7748/ns2011.11.26.12.30.b1288

Task 2

Description of the sentimental event

The pre-op nurse at the Nightingale Community Hospital informed Tina’s mother that the time she would spend at the OR surgery would be 45 minutes and one hour recovery time. The mother decided to go on an errand but left her contacts with the nurse in case her daughter recovered earlier than expected. She returned two and half hours later, and she was marred with distraught on the realization that Tina had been discharged. Law enforcement officers were called who also contacted the hospital security, and a search followed. She was located under the care of her father who took her as they waited for he mother. The CEO of the hospital assured Tina’s mother that the incident was to be analyzed and amicable solutions put in place to avoid similar happenings in the future.

Role of the personnel present during the ordeal

Roles of pre-op nurses

The primary role of the pre-op nurse is the evaluation of the physical and mental state of the patients that visit a health facility for a planned surgery. They do so by asking the patients question regarding their health using a questionnaire (Campbell, 2011). The pre-op nurses also discus with the patients about their social and medical histories with the aim of collecting detailed information. They also check the patient’s blood pressure or carry out an investigation on the patient’s blood tests before surgery.

Barriers that may impend effective interactions between the personnel and patient

During the sentimental event, there are various barriers that may impend with interactions among the personnel that was present. One of them is poor communication between the pre-op nurse and Tina’s mother. It is because of the misunderstanding in communication that there were poor interaction and delivery of message. The pre-op nurse informs the mother to Tina about the surgery and recovery completion times which are hardly accurate. Tina’s mother gave the pre-op nurse a number for her to contact her after the surgery was completed earlier than expected but this hardly happened. Subsequently, when the mother comes back to the hospital for her daughter, she is missing in action.

In the quest for addressing the communication barrier, it would have been effective for the pre-op nurse to provide Tina’s mother with accurate surgery completion and recovery times. She was also supposed to assure her about the child’s safety even if she was to be discharged earlier than expected. On her side, the pre-op nurse, having been given the cell phone number, was supposed to remind Tina’s mother about her recovery. Finally, on the bigger picture, Tina’s mother was supposed to cancel her errands and instead wait until her daughter recovered and was discharged from the hospital.

Quality assessment tool to be used in the conducting of root-cause analysis

A fishbone (Ishikawa) diagram will be essential in conducting a root-cause analysis in the sentinel event. The quality assessment tool is designed in such a way that it easily identifies the causes of the problems and highlights on some of the measures that can be embraced in handling the challenges. In Tina’s case, the Ishikawa diagram will identify the causes of the problems at hand any effects and suitable solutions that can be embraced in dealing with the issue.

Recommendation of a risk management program that will ensure that the problem doesn’t recur

Nightingale Community Hospital needs to come up with stringent measures that ensure that the safety of all the patients that visit the facility is assured. In order to mitigate the chances of future occurrence of Tina’s case, in the future, the hospital will have to adopt a risk management strategy that will see to it that all the patient’s information is collected by both the hospital security and the attending medical staff on duty (Grol & Ouwens, 2013). Children will be brought to the facility on the custody of either of their parent, who will not be required to leave until she or he is discharged. It will be the role of the pre-op nurse to provide the patients with accurate information on the durations of the surgical process as well as the recovery time. Only the pre-op nurse on duty will be required to clear the patient. The patient will also have to sign out of the facility at the security office (Lorenzi & Riley, 2004). With all these measures in place, the safety of the patients at the Nightingale Community Hospital will be bolstered, and this will avoid similar occurrence such as that of Tina, in the future.

There are various resources that support the changes to be implemented within the Nightingale Community Hospital. Grol and Ouwens (2013), in their article, Planning of change implementation¸ focuses on the changes that healthcare organizations can embrace in ensuring that they witness an enhancement in their operational efficiencies. The ideology is supported by Lorenzi and Riley (2004), in their article Change Management for Successful Implementation.

References

Campbell, P. (2011). Nursing Management: Principles and Practice – Second editionNursing Management: Principles and Practice – Second edition. Nursing Standard, 26(12), 30-30. doi:10.7748/ns2011.11.26.12.30.b1288

Grol, R., & Ouwens, M. (2013). Planning of change implementation. Improving Patient Care, 289-303. doi:10.1002/9781118525975.ch19

Lorenzi, N. M., & Riley, R. T. (2004). Change Management for Successful Implementation. Managing Technological Change, 99-109. doi:10.1007/978-1-4757-4116-2_7

Task 3

Outstanding patient care issue

The 67-year old female patient had a laparoscopic hysterectomy, and as a result of excessive bleeding, it was converted to an open procedure, five weeks before her hospitalization. Seven days ago, she developed fever and drainage that led to her possible postoperative infection. She had surgery, five days ago that aimed at treating the abscess formed during the surgical procedure that she had earlier gone through. The patient is at risk of falls, thus the need for proper management. She is scheduled to go home, and a home health will provide oversight of the anti-biotic therapy.

Corrective action plan to address the patient’s situation

Root causes or opportunities for improvement

The 67-year old female patient initially had a laparoscopic hysterectomy but ended up resulting in excessive bleeding, and this led to an open procedure five weeks before she was hospitalized. The possibility of postoperative infection was driven by the fever and drainage that she developed seven days ago. Five days ago, she went through a surgical procedure that was aimed at treating the abscess formed during surgery. Her discharge plan entails home health to provide oversight of the antibiotic therapy.

Risk reduction strategy

The nurses will play a critical role in the verbalization of the medication reconciliation process that will be essential in the patient’s care. Both functional and nutritional assessments will be conducted. All the patient’s risks will be documented and suitable measures put in place. Nursing plan of care will be updated on a regular basis to ensure that the patient’s recovery process is enhanced after she is discharged (Yang, Fang & Huang, 2007). An on-going patient education will be carried out, and with the help of her supportive spouse, this will be a success. Patient’s pain will be assessed at least every four hours, and this will be done on a scale of 0-10. A follow-up will be done on the patient, after she is discharged to ensure that her recovery is smooth.

Person responsible for the implementation of the risk strategy

The risk strategy will be implemented by the Advanced Practice Registered Nurse (Edgar Davids) and a specialist surgeon (Florence Whitefield) within the health facility. Both of them will see to it that the risk management strategies are functional and are applicable in the Nightingale Community Hospital to help in dealing with similar cases in the future.

Target date of implementation

Verbalization of medication reconciliation process:-2nd-4th December 2017

Functional and nutritional assessment:-5th-8th December 2017

Documentation of patient’s risks:-8th December 2017

Nursing care plan update:-10th-15th December

On-going patient education and assessment of patient pain:-Regularly from the day of admission

Patient follow-up-17th December till the patient recovery date

Location of implementation

The risk management strategies will be implemented at the Nightingale Community Hospital, and this will be done during the period upon which the patient will be admitted. Additional implementation will be conducted at her home after her discharge from the health facility.

Completion date

The completion date for the entire implementation process will be on 17th December 2017.

Performance indicators or measures of effectiveness

Some of the performance indicators that will be embraced as a part of the action plan will include, the patient’s recovery process as well as her reaction to the implemented risk management strategies. A positive reaction will imply efficiency of the risk management strategies and vice versa (Yang, Fang & Huang, 2007). Additionally, a quick recovery process will be an indication of the effectiveness of the adopted risk management strategies.

References

Yang, C., Fang, S., & Huang, W. (2007). Isomorphic pressures, institutional strategies, and knowledge creation in the health care sector. Health Care Management Review, 32(3), 263-270. doi:10.1097/01.hmr.0000281627.22526.ee

Task 4

Current compliance status of the healthcare facility

At the Nightingale Community Hospital, fire safety is mandatory, and one drill is conducted per shift per quarter. The facility abides by the Joint Commission Standards, and this is evidenced by the Endoscopy Department’s monthly moderate sedation audit. Patient’s information documentation is also in compliance with the Joint Commission Standards. A prohibited abbreviation audit is conducted by the firm on a monthly basis. The hospital provides patient education and training based on their individual needs. A pain assessment audit is done regularly within the hospital, and this is usually done in line with the Joint Commission Standards.

Trends that may cause the organization to fail in complying with the Joint Commission Standards

The communication strategies embraced by the hospital are ineffective. Based on the abbreviation audit report, it is evident that there are a lot of inconsistencies that may end up leading to the firm’s negative productivity. Errors in the presentation of information that arise as a result of the inability of the company to comply with the communication area of the Joint Commission Standard may end up leading to inaccurate medical prescriptions, thus a deterioration in the public trust. Patient education and training is done on a regular basis but has on several occasions failed to meet the company’s set goals and objectives.

Staffing pattern of the patient care unit

Staffing effectiveness is an instrumental aspect of any organization. The success of any company is dependent on various factors, and one of them is the productivity levels for its workers (Chevalier, 2007). In the quest for the determination and enhancement of the staffing effectiveness, Nightingale Community Hospital uses data from the service screening indicators and the human resource screening. Some of the clinical indicators include falls prevalence, pressure ulcer prevalence and falls with injury. Human resource indicators, on the other hand, include nursing care hours and overtime.

In the financial year of 2009, the oncology staff unit experienced falls and nosocomial pressure ulcer rates. The year-end average for falls per 1000 patient per day for the unit stood at 5.45%. There was also a decline in the nosocomial pressure ulcer rate from 2.76% in the year ending 2008 to 1.23% in the year ending 2009. During the same year, the 4E experienced an increase in the patient falls and nosocomial pressure ulcers. The falls per 1000 patients’ days increased significantly from 1.47 to 4.37%. In the Intensive Care Unit, the average year-end fall in 2009 was 1.9, and this was higher compared to 0.47 that was recorded in the previous year. Ventilator Associated Pneumonia improved from 2.2 per 1000 ventilators days (i.e. one infection per day) to 3.0 in 2009 (two infections). In as much as there was an increase in the number of falls in the ICU, there was hardly a correlation with the number of working hours for the nurses. Some of the actions that were embraced by the organization, with the aim of enhancing VAP included mouth care protocols, sedation vacation and intensives rounds. Based on the provided information, it is evident that the organization is faced with instances of staff falls and reduced productivity.

Staffing plans

There are various measures that the Nightingale Community Hospital can embrace in ensuring that it minimizes the number of falls witnessed in the patient care unit. The accreditation director and the nurse manager will have to ensure that they push the HR Department to hire more qualified medical workers. With a high nurse to patient ratio, the number of falls will be reduced significantly. Currently, most of the employees in the patient care unit are disgruntled due to the poor reward and recognition system that the company has embraced. It will thus be vital for the accreditation director to come up with an employee motivation program that will be critical in the enhancement of the staff members at the patient care unit (Anderson & Bolt, 2013). A charged and motivated workforce will be on the frontline in the minimization of the number of falls. Finally, implementation of effective communication strategies within the department will be essential in bolstering staff effectiveness, thus better patient outcomes.

References

Anderson, L. E., & Bolt, S. B. (2013). Professionalism: skills for workplace success. Boston: Pearson.

Chevalier, R. (2007). A managers guide to improving workplace performance. New York: AMACOM, American Management Association.