Nightingale Hospital Periodic Performance Review Case Study

Periodic Performance Review (PPR) tool is used by Nightingale Community Hospital to examine its internal processes so that the facility complies with Joint Commission Standards. The Periodic Performance Review lays focus on the processes, methods, and procedures that the hospital uses with the objective of identifying if the required standards are met. For any institution to receive accreditation from the Joint Commission, 251 standards have to be met. Based on the evaluation, Nightingale hospital only complies with 234 standards (Baird, Tung & Yu, 2017). The major issues of compliance lie in the following areas: medical staff, national patient safety goals, universal protocol, provision of service, treatment and care, medication management, information management, life safety, record care and environment care. The joint Commission ensure that the patients continue to receive proper care. The accreditation offers assurance to the visitors, staff, and the patients that the facility meets the minimum required standard and that it is capable of providing proper care. The Joint Admission’s accreditation process is performed by experts through record assessment and interview reviews.

Based on the review the hospital is performing relatively well in numerous area. However, the PPR indicated that there are numerous areas that require improvement.

Trends Evident In the Accreditation Audit Case Study

a. Medical Staff

During the policy review and medical staff interview, it was noted that the OPPE process failed to meet the standard MS.08.0101.

b. The National Patient Safety Goal

In the Periodic Performance Review roundup, it was noted that some of the syringes, as well as the basins from the external suppliers, did not have the labels meaning they did not comply with the NSPG.03.04.01 requirement.

The healthcare medications, as well as syringes of containers, should be pre-labeled to ensure there is no mix-up. This is prudent in minimizing error because of the improved safety management.

c. The Universal Protocol

During the audits, it was discovered in the OR there was a sentimental event because the Knee arthroscopy was not marked. In addition, the bronchoscopy lab lung biopsy had not been marketed.

The universal precool is critical because it ensures that the wrong site surgery sentimental event is avoided. Before giving anesthesia the surgeon should assess the area where the surgery is supposed to be performed and mark it.

d. Life Safety

The linen carts, the litters, the stretchers, and the mobile carts were stored in the hallway. The items had blocked the fire extinguishers. This meant that in an event of a fire the fire extinguishers could not function appropriately. This was a contravention of standard LS.03.01.20. The fire drill that was conducted by the facility did not comply with the requirements of EC.02.03.03.

The fire drill should be performed as per the standards. This ensures that the members of staff are prepared to act swiftly in case of a fire outbreak. The fire drill offers vital skills that can help to save lives.

The storage of items in the passageway is not always a good idea because it hampers swift movement in an event of an emergency. In addition, blocking the fire extinguishers may render them useless in an event of a fire outbreak.

e. The Provision Of Care

The audit also reviewed the provision of various services, treatment, as well as care. It was noted that the patient’s assessment, as well as reassessment, was not documented in the medical records. The documents also lacked the date when various procedures were performed; there was no reliable process evident in the surgery pre-op, endoscopy unit, and Cath lab. The endoscopy did not have a plan for anesthesia. Because of the shortfall, the hospital did not comply with standard PC.01.02.07, standard PC.03.01.03, and PC.01.02.03.

f. Medication Management

In an interview with the nurses, one of them couldn’t explain the policies are utilized, another nurse did not follow a wide range of policies. In both cases, they were not compliant with standard MM.04.01.01. Moreover, the syringes did not have the identification label. This meant that the facility did not comply with standards NPSG.03.014.01 and MM.05.01.09 (Subhan, 2017).

Based on standard MM.04.01.01 the nurses ought to have a thorough understanding policy in order to understand the particular order to be executed. Standards NPSG.03.014.01 and MM.05.01.09 stipulate that the medications that are administered by another practitioner other than the one preparing it has to be labeled. The labels can include any cautions that the individual providing the medication should know prior to administering, the name of the patient, the direction on how to use and the administration site.

g. Nursing Leaders

The interviews that were conducted with various nurses revealed various shortfalls in the facility. It was discovered that the hospital had inadequate staff leading to a higher nurse to patient ratio; this was a contravention of standards NR.02.02.01 and standard LD.03.06.01 (Subhan, 2017).

The Chief Nurse Executive should ensure that the hospital has enough nurses as a way of reducing burnout. The adequate nurses will also ensure that patients receive appropriate care around the clock.

h. Information Management

During the chart reviews as well as audits, abbreviations were noted in the physician orders, nursing notes, and progress orders which contravenes standard UP.01.02.01. The nurses did not authenticate the verbal orders within 48 hours which lead to misrepresentation errors.

i. Environment Of Care

An audit of the EOC also identified numerous shortfalls. The gift shop did not conform to the 18 inches permissible prerequisite for the sprinkler. There was no interim support measure in the records during construction. The shortfall indicated that the facility did not comply with standard LS.03.01.35, standard EC.02.03.01, LS.01.02.01, and standard EC.02.05.09 (Subhan, 2017).

The smoke rooms in the hospitals allow for toxic fumes and smoke to pass through to other areas of the facility a fact that might have severe consequences on both the patients and the staff. The healthcare facility ought to repair the area to reduce risks of smoke poisoning.

The facility should have 18 inches of space between the storage and the sprinkler head to facilitate maximum performance. The closeness of the sprinkler to the storage is a major risk because it might fail to put out the fire in an event of an emergency.

A health care facility ought to have an interim life safety measure policy. The absence of this crucial policy is an indicator that the safety standards were violated in the construction phase. Such a violation show that the area is riskier for both staff and patients.

The performance improvement and chart review indicated that standard RC.02.03.07 was violated. The verbal orders were never authenticated within forty-eight hours as per the state laws. Quicker authentication reduces the chances for a misrepresented order.

j. Record Safety

The audit that was conducted on the Performance improvement and the Chart review showed that the verbal orders in the healthcare facility were not authenticated within forty-eight hours which is in accordance with standard RC.02.03.07.

Based on the provisions of the Joint Commission the verbal order ought to be authenticated within forty-eight hours after the order is given. The likelihood of misinterpretation is prevented when the provision is observed.

k. Other Trends

The lapses in meeting the standard might have an adverse impact on the healthcare’s ability to offer proper care to the patients. For instance, the history of the fire drill indicated that they were performed once per dill per quarter. Such a lapse indicates that the staff will not be prepared in an event of fire emergency (Baird, Tung & Yu, 2017). The Joint Commission places greater value on the patient’s safety. The patient fall data indicated that there were about 3.6 falls per 1000 inpatient days. The statistics exceed the Joint Admission goal of less than 3.21 (Figure 2). Nevertheless, the number of the patient fall with injury is within the required limits of 0.62 (Figure 1).

Figure 1. From Patient Falls Hospital-Wide

Figure 2. From Patient Falls Hospital-Wide

Figure 3. From Pain Assessment Audit

Figure 4. From Fire Drill History

Performance Improvement Standard

Analysing the Data

The reports assess the two units: the ICU, 4 East, and the 3 East. The ventilation associated with pneumonia and the fall prevalence are compared to nursing care hours in the intensive care unit. In addition, the fall with injury is compared with fall prevalence in the nursing hours in the form 4-East. The various institution employs such kind of metric with the objective of improving the quality of services as well as the care they offer patients. In this case, the lesser the prevalence rate, the better the services different customers receive. An adequate or higher nursing ratio can be associated with better healthcare services that will lead to reduced hospital-related mortality, pneumonia as well as cardiac arrests (Honda & Iwata, 2016). The data that was collected from the intensive care unit indicated that there was a rise in the number of falls. The trend had no relationship to the nurse hours. In general, the data from 3-East showed that there was no notable negative trend. The data did not indicate a correlation between the fall in the 4 East and the nursing care hours.

Staffing Plan

As per the statistics presented in Figure 5, there was a linear correlation between the nursing care hours per patient and the fall per 1000 patient. The trend shows that the hospital doesn’t have the adequate nursing staff to prevent the falls from taking place. The best solution to such a problem is to increase the number of nurses in the facility. The data point showed a varying need for nurses at different times of the year. The trend indicates that the hospital can employ a flex-schedule. This will involve employing more nurses at the time certain times of the year to serve the swelling number of the patient at certain times of year and reducing the number if the sum of patients declines.

Figure 5 A report on the effectiveness of staff

Employing intermediate nurses is the best solution to the shortage being witnessed at the moment. The report recommends that the facility should have at least one registered nurse as well as one licensed practical nurse at every time in the facility during normal hours. The presence of intermediate nurses will reduce the number of patients that each registered nurse is required to serve (Jin & Ha, 2017). However, as the rate of patients increases the intermediate nurses should be called to bolster the increased acuity. In an event of an increase in the inflow of patient, the facility will require 15 intermittent registered nurses and 12 permanent registered nurses to cover both the shifts appropriately. The method is likely to stabilize the nursing care that each patient receives, to reduce the number of falls per 1000 patient, and to minimize overtime.

References

Baird, K., Tung, A., & Yu, Y. (2017). Employee organizational commitment and hospital performance. Health Care Management Review, 1. doi: 10.1097/hmr.0000000000000181

Honda, H., & Iwata, K. (2016). Personal protective equipment and improving compliance among healthcare workers in high-risk settings. Current Opinion In Infectious Diseases, 29(4), 400-406. doi: 10.1097/qco.0000000000000280

Jin, M., & Ha, Y. (2017). Influencing Factors on Hospital Fall Prevention Activities of Tertiary Hospital Nurses and General Hospital Nurses. Journal Of Health Informatics And Statistics, 42(4), 361-370. doi: 10.21032/jhis.2017.42.4.361

Subhan, A. (2017). 2017 Joint Commission Medical Equipment Standards. Journal Of Clinical Engineering, 42(2), 56-57. doi: 10.1097/jce.0000000000000201