New Mexico State University Accreditation Audit AFT Task

INTRODUCTION

The accreditation process seeks to help organizations identify and resolve problems and to inspire them to improve the safety and quality of care and services provided. The process focuses on systems critical to the safety and the quality of care, treatment, and services.

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For this task, you will assume the role of director of accreditation. You will review and analyze the materials (e.g., records, previous audit, trends, e-mails) provided in the case study to prepare for the audit. You will need to look across all departments and examine trends and patient care issues to determine readiness.

A.  Facilitate an organization’s continuous accreditation compliance process as you determine the readiness for the accreditation audit of the healthcare facility in the attached Accreditation Audit Case Study – Task 4 Artifacts by doing the following:

1.  Discuss the current compliance status of the healthcare facility by including the compliance status of each of the 18 Joint Commission standard focus areas.

2.  Discuss at least two trends evident in the Accreditation Audit Case Study – Task 4 Artifacts that may cause the organization to not be compliant with the Joint Commission standards for patient care.

3.  Review the performance improvement standard regarding staffing in the healthcare facility’s patient care unit by doing the following:

a.  Analyze the data to determine the staffing patterns of the patient care unit.

b.  Develop a staffing plan to minimize the number of falls in the patient care unit.

YOU MADE IT TO THE
END
AFT 2 TASK 4
Presented by- Dr. R. Austin Arenz III DM,
MSM/MHR, MPA, aPHR, MBAHC, MPH, RT
Task 4 – Getting Started
 You are role playing as
the Director of
Accreditation for
Nightingale Hospital.
 You are providing a status
report, to senior
leadership, regarding
compliance with patient
safety measurable.
Preparing for AFT2 Task 4
 Open the Panopto Video Links.docx. document that
was previously downloaded.
 Open video 4. Watch video.
Preparing for Task 4 continued
 Click on Course Tips from the document that was
previously downloaded.
 Review Task 4 tips.
 This document contains tips and step-by-step
instructions for completing each of the tasks
Preparing for
Task 4
continued

Open course in Task Stream

Click on Task 4. You will find
two files attached.

Accreditation Audit
Case Study – General
Artifacts

Accreditation Audit
Case Study – Task 4
Artifacts


Click on the zip file

Download 9
documents.
Click on Evaluation
Method – rubric

Download
Task 4 – Preparing the paper
 Header 1 – Compliance Status
 You will review the status of Nightingale
Hospital.
 Open the FSA findings document. This provides
all the non-compliant findings from inspections.
Task 4 – Preparing the paper

Header 1 – Compliance Status continued

Determine what is deficient by going to the JC manual and
determine what should be in place. Click on Course Tips in the
Course of Study in Mentor Force

Click on view all (upper right corner under the Course Tips header)
 Locate the link to the JC Electronic Manual.

Determine the compliance status by crossing off all
standards that are not in compliance.

You will summarize, to senior leadership, all those
standards that are in compliance AND why they are
important.
 Look at Overview and About this Chapter in the JC
manual. These areas provides an explanation of the
importance of that standard.
Task 4 – Preparing the paper

Header 1 – Compliance Status continued

The non-compliant items should be
grouped in a way that makes sense to you
either by patient care area, accreditation
function, or any other method you choose

Non-compliant items- The ones
that are not in compliance just
give an example from the FSA
findings of the where they are
not in compliance!

You will also note ONE area that is not
in compliance, discuss and provide
example (s).
Possible Format/Minimal
Requirements
1) ******

List Compliant &why they are
important

1.) HR- Need qualified staff……

2.) Until all are listed with
importance

One non-compliant from the FSA
sheet only. Describe what failed

Next section Non-compliant
trends(see slide 10) this has
nothing to do with the FSA sheet!
You must pick from slide 10.
2) *********
3) ********
4) ********
5) ********
6) ********
7) ********
8) ********
18) ********
Not part of the Non-compliant
List

Header 2 – Non-compliant
trends
 You will discuss the trends of
what is happening at
Nightingale.
 Look at the audit documents
and determine what factors
led up to the non-compliant
finding. (discuss two areas)
Task 4 – Preparing the paper
 Header 3 – Staffing Patterns
 This area speaks to areas that
Nightingale attempted to improve.
 Look at the Staffing effectiveness
report.
 Articulate what you see in the
graphs, related to staffing
patterns for 3E, 4E, and ICU
when comparing ulcers and falls.
Task 4 –
Preparing the
paper

Header 4 – Staffing Plan

Develop a staffing plan for 4E to
minimize the number of falls.
 3 types of professionals (RNs,
LPNs, CNAs)
 Submit a graph illustrating the
number of each professional
by shift (day, evening, night)
 Provide an explanation on
why these numbers are
needed to minimize the
number of falls.

Header 5 – Sources
A Simple Chart Version
# of RN # of LPN # of CNA
Day
Evening
Night
Task 4 – Final Thoughts
 Tips for success
Make sure that you stay objective
Keep it simple, but detailed – follow rubric
expectations
Avoid copying words directly from JC –
increases likeliness %
Write as if you are the Director of Accreditation
providing a report to Senior Management, not as
a student submitting a paper for grading.
 Submit paper – YEAH!
Contact Information
Dr. Russell “Austin” Arenz III
Austin.arenz@wgu.edu
EXT-4976
Fire Drill History
At Nightingale Community Hospital, we require one drill per shift per quarter. Listed below is the history of this
past year’s drills.
Month
1st Shift
January
3E
February
March
2nd Shift
3rd Shift
5E
Telemetry
April
ICU
May
PACU
ED
June
Rehab
July
3E
August
Pre-op Surgery
September
5E
October
Pharmacy
November
4E
December
Radiology
NOTE: Standards not addressed in this document are all compliant with The Joint Commission standards.
Finding
Smoke wall penetrations noted (>3)
Source
Observation during PPR
rounds
Accreditation Function
Environment of Care
Impact
Direct
Reference Std
EC.02.03.01
3E
Nurses on 3E consistently do not document in timely manner
resulting in overtime and low morale—when asked
why—answered they were “too busy”. This generated
discussion re: staffing pattern and nurse to patient ratio and
adequacy of staffing.
Interview with staff
Nursing
Leadership
Direct
NR.02.02.01
LD.03.06.01
3E
Verbal orders not authenticated within 48 hours
Chart review during PPR
rounds and PI audit
Clutter in hallways (Mobile computers, Med Carts, stools, linen Observation during PPR
carts, stretcher in front of fire extinguisher)
rounds
Record of Care
Indirect
RC.02.03.07
Life Safety
Indirect
LS.03.01.20
3E
Prohibited abbreviations found in progress notes, nursing
notes, and/or physician orders
Audit
Information Management
Direct
IM.02.02.01
4E
Nurse did not follow range order policy.
Interview with staff
Medication Management
Indirect
MM.04.01.01
4E
Prohibited abbreviations found in progress notes, nursing
notes, and/or physician orders
Verbal orders not authenticated within 48 hours
Chart review during PPR
rounds
Chart review during PPR
rounds and PI audit
Clutter in hallways (stretcher in front of fire extinguisher; linen Observation during PPR
cart stored in hall )
rounds
Information Management
Direct
IM.02.02.01
Record of Care
Indirect
RC.02.03.07
Life Safety
Indirect
LS.03.01.20
Smoke wall penetrations noted
Observation during PPR
rounds
Environment of Care
Direct
EC.02.03.01
5E
Verbal orders not authenticated within 48 hours
Cardiac Cath Day of Procedure Reassessment missing in numerous
Lab
cases—no consistent process
Chart review
Audit
Record of Care
Indirect
Provision of Care,
Indirect
Treatment and Services (PC)
RC.02.03.07
PC.01.02.03
ED
Verbal orders not authenticated within 48 hours
Record of Care
Indirect
RC.02.03.07
ED
Pain assessment & reassessment consistently missing in ED
records
Chart review during PPR
rounds and PI audit
Audit
Provision of Care,
Direct
Treatment and Services (PC)
PC.01.02.07
1st floor
3E
4E
4E
4th floor
Endoscopy
Day of Procedure Reassessment missing in numerous
cases—no consistent process
Audit
Provision of Care,
Indirect
Treatment and Services (PC)
PC.01.02.03
Endoscopy
Lack of pre-sedation ASA and no documented plan of
anesthesia noted in endoscopy
Audit
Provision of Care,
Direct
Treatment and Services (PC)
PC.03.01.03
Endoscopy
ICU
Bronchoscopy lab lung biopsy—side not marked
Nurse could not explain how range dose policy is executed.
Sentinel Event
Interview with staff
Universal Protocol
Medication Management
Direct
Indirect
UP.01.02.01
MM.04.01.01
ICU
Audit
Information Management
Direct
IM.02.02.01
OR
Prohibited abbreviations found in progress notes, nursing
notes, and/or physician orders
Propofol syringes found unlabeled in OR and Cath Lab
Medication Management
Direct
OR
Unlabeled basins observed
Direct
Prelabeled syringes in cataract packs from external supplier
National Patient Safety
Goals (NPSG)
National Patient Safety
Goals (NPSG)
MM.05.01.09
NPSG.03.04.01
NPSG.03.04.01
OR
Observation during PPR
rounds
Observation during PPR
rounds
Observation during PPR
rounds
Direct
NPSG.03.04.01
OR
Clutter in hallways (stretchers and surgical equipment)
Observation during PPR
rounds
Life Safety
Indirect
LS.03.01.20
OR
Knee arthroscopy site not marked
Sentinel Event
Universal Protocol
Direct
UP.01.02.01
PI data
Verbal orders not authenticated within 48 hours
Chart review during PPR
rounds and PI audit
Audit
Record of Care
Indirect
RC.02.03.07
Surgery Pre- Day of Procedure Reassessment missing in numerous
op
cases—no consistent process
PC.01.02.03
Provision of Care,
Treatment and Services (PC)
Telemetry
Prohibited abbreviations found in progress notes, nursing
notes, and/or physician orders
Audit
Information Management
Direct
IM.02.02.01
Telemetry
Verbal orders not authenticated within 48 hours
Record of Care
Indirect
RC.02.03.07
Telemetry
Clutter in hallways (Mobile computers and Med Carts)
Chart review during PPR
rounds and PI audit
Observation during PPR
rounds
Life Safety
Indirect
LS.03.01.20
EOC
Appropriate ILSM not initiated during 3 construction projects
Review of Facilities
Department documentation
Environment of Care
Direct
LS.01.02.01
EOC
Gift Shop did not have required 18” clearance from sprinklers
Observation
Environment of Care
Indirect
LS.03.01.35
EOC
Master alarm panel for medical gasses was not tested annually Review of Facilities
per policy.
Department documentation
Environment of Care
Direct
EC.02.05.09
EOC
Fire drill processs not adequate; frequency does not meet
standards
Fire Drill History Report
Life Safety
Direct
EC.02.03.03
Med Staff
OPPE process does not meet standards
Interview with Medical Staff
Office and review of policy
Medical Staff
Indirect
MS.08.01.01
Moderate Sedation Monthly Audit: Endoscopy Department
Pre-procedure:
H&P/Assessment complete
Mallampati Classification complete
ASA determined
Sedation Plan documented
Reassessment complete
Evidence of informed consent
Aldrete score recorded
Baseline VS recorded
Time Out documented
Medications administered in incremental doses
During procedure:
Vital signs recorded every 5 minutes during procedure
Oxygen saturation recorded every 5 minutes during
procedure
Patient’s response to medication recorded every 5 minutes
during procedure
Post procedure:
VS monitored (minimum): Immediately post procedure
VS monitored (minimum): 15 minutes
VS monitored (minimum): 30 minutes
Oxygen saturation monitored (minimum): Immediately
post procedure
Oxygen saturation monitored (minimum): 15 minutes
Oxygen saturation monitored (minimum): 30 minutes
Discharge criteria met
Evidence of instructions reviewed with patient/caregiver
Q1
% Compliant
Q2
Q3
Q4
92
80
80
80
85
99
99
97
100
90
99
81
81
81
88
100
99
96
100
93
97
78
78
78
85
100
99
98
99
92
98
79
79
79
89
100
100
99
100
96
92
92
95
95
94
94
93
93
90
95
90
93
96
96
92
96
97
97
89
97
94
94
91
94
98
98
88
98
96
75
95
99
97
76
94
98
94
84
96
100
98
87
97
99
Pain Assessment Audit
Pain Assessment Audit
100
99
92
82
98
94
75
75
99
90
9196
9695
70
71
73
3
4
5
9796
95
99
95 94
70
68
66
6
7
8
9495
90
95
96
93
9598
70
70
9
10 11 12
65
68
50
25
0
1
2
ED
3E
PACU
Pain Reassessment Audit
100
9292
9190
9593
9195
98
96
9793
90 91
75
93 90
93
91
90 92
66
60
50 42
47
52
53
54
5
6
57
97
93
61
9698
59
53
54
9
10 11 12
25
0
1
2
3
4
ED
3E
7
8
PACU
Patient Falls in 4E
4-East
Falls with Injury
Target 0.62
4.5
Per 1000 Patient Days
5
4
3
0
0
Jan
Feb
3.8
2.4
2
1.72
2
1
4.1
3.8
0
0
0
0
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
4-East
Falls per 1000 Patient Days
Target 3.21
Per 1000 Patient Days
15
11.9
8.3
10
7.9
5.6
4.58
5
4.37
1.72
0
8.9
7.6
4.37
0
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Patient Falls Hospital-Wide
Falls per 1000 Inpatient Days—Hospital-Wide
Target < 3.21 6 5.1 4.9 5 3.8 4 2.8 3 2.4 4.7 4.2 4.2 3.5 2.8 2.3 2.1 2 1 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Falls with Injury per 1000 Inpatient Days—Hospitalwide Target

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