AFT Task 1 summer 2021 PDF

Preview

Summary

At the end of this section, you will be able to outline a process for a given healthcare organization to comply with an accrediting agency, and develop a compliance plan for a given healthcare organization to meet accrediting regulations....

Description

Running head: AFT TASK 1

1

AFT Task 1 Reagan Wheeler Western Governors University

AFT Task 1

2 AFT Task 1 Communication

The first Standard under Communication stated, “Conduct a pre-procedure verification process.” There are three elements of performance under the first standard. The first element requires the hospital to have a pre-procedure process verifying the correct procedure, for the correct patient, at the correct site. There is a Policy under the named Site Identification and Verification (Universal Protocol) called the Preoperative/Pre-procedure Verification Process. The hospital is compliant with the first element. The second element requires the hospital to “Identify the items that must be available for the procedure and use a standardized list to verify their availability.” There is a Pre-procedure Hand-Off checklist that is to be done by the preoperative nurse and the circulating nurse. Relevant documentation and labeled diagnostic and radiology test results are on the checklist. Any required blood products, implants, devices, and/or special equipment needed for the procedure are discussed and provided in the hospital's TimeOut procedure. The hospital complies with the second element. The third element requires the hospital to have a procedure or policy is in place that allows items to be matched to the patient at all times. There is no written policy or communication for the items that are to be available in the procedure area to the patient. The hospital is not in compliance with the third element. The second standard under communication stated, “Mark the Procedure Site.” There are five different elements of performance under this standard. The first element requires that the hospital have a policy or procedure in place to identify the procedures that need a marking of the incision. There is a Policy under the named Site Identification and Verification (Universal Protocol) called the Marking the Operative/Invasive Site. The hospital complies with this element. The second element requires the hospital to mark the procedure site before the

AFT Task 1

3

procedure. The Pre-procedure Hand-Off checklist that is to be done by the pre-operative nurse and the circulating nurse includes a spot to be checked off on where the patient has been marked or not. Marking the Operative/Invasive Site Policy also stated that the patient must be marked before the procedure. The policy also states that the patient must be active in participation if the patient is awake. The hospital policy complies with the second element. The third element requires the procedure spot to be marked by a licensed practitioner. Marking the Operative/Invasive Site Policy does not ever clearly state who should be marking the patient site. The hospital does not have a policy and is therefore not in compliance with the third element. The fourth element requires the marking site to be used consistently throughout all procedures and one that is not going to wear off. The Marking the Operative/Invasive Site Policy clearly states “The mark should be made with a permanent marker that will remain visible after skin prep.” The hospital complies with the fourth element. The fifth element requires the hospital to have a written, process in place for patients who refuse surgery site markings, The Marking the Operative/Invasive Site Policy has a list that is exempt from marking. These procedures require justification in the preoperational checklist. They have also stated that x-ray, needle localization, and physician notification are allowed as alternative processes. The hospital complies with the fifth element. The third standard requires the hospital to have a time-out before the procedure. There are five elements of performance attached to this standard. The first element requires the hospital to immediately do a time-out before starting an invasive procedure. The Time-Out Procedure Policy states “Immediately before beginning the procedure, the nurse or technologist is responsible for calling the time-out.” The hospital complies with the first element. The second element requires the hospital to make sure there is a standard set of information for all operating rooms in the hospital. The Time-Out Procedure Policy includes a standardized timeout

AFT Task 1

4

questionnaire, it is initiated by the circulating nurse or the scrub technologist and involves immediate members of the operating room team. The hospital complies with the second element. The third element requires the hospital to have a policy in place for doing a time-out when two or more procedures are being performed on the same patient. The Time-Out Procedure Policy does not ever state what to do in the case when two or more procedures are being performed on the same patient. The hospital’s policy is not in compliance with the third element. The fourth element requires the hospitals to have a Time-Out Procedure Policy that includes the patient’s identity, correct site, and correct procedure. The hospital complies with the fourth element. The fifth element requires hospitals to document the completion of a timeout. The Time-Out Procedure Policy does not include any statements about documenting the timeout. The hospital is not in compliance with the fifth element. Plan for compliance The first Standard under Communication stated, “Conduct a pre-procedure verification process.” The third element of performance for this standard was not compliant. There is no policy on labeling patients in the operating rooms. There is also no policy on labeling the supplies and equipment that are needed in the operating room for that particular patient. The Surgical Leadership Committee needs to have a policy written about matching the items that are to be available in the procedure area to the patient. A procedure needs to be written with the next week. Once established the policy needs to be monitored for the next 6 months every two weeks to make sure no changes need to be made. The manager of the surgical services department will monitor this change and make sure that it is effective and happening in all of the pre-procedure and procedure rooms All staff involved should be properly trained.

AFT Task 1

5

The second standard under communication stated, “Mark the Procedure Site.” The third element of performance for this standard was not compliant. There is no policy stating who should be marking the patient for the procedure. The Surgical Leadership Committee needs to create a policy immediately. Only licensed independent practitioners and those who are licensed underneath of them including their medical students, nurse practitioners, and physician assistant, who will be in the procedure, are allowed to mark the patient's procedural site. All staff involved should be properly trained. The third standard requires the hospital to have a time-out before the procedure. The third element of performance for this standard was not compliant. There was no information under the Time-Out Procedure Policy stating a timeout needs to be done in between each procedure when two or more procedures are going to be done, and the surgeon performing the procedure changes on the same patient. The Surgical Leadership Committee needs to add this to the policy immediately. The manager of the surgical services department will monitor this change and make sure that it is effective and happening in all of the procedure rooms. All staff involved should be properly trained. The fifth element of performance for this standard was not compliant. There was no information under the Time-Out Procedure Policy stating that the time-out needs to be documented. The time-out completion must be documented somewhere within the patient chart. The Surgical Leadership Committee needs to add this to the policy immediately. The manager of the surgical services department will monitor this change and make sure that it is effective and happening in all of the procedure rooms. All staff involved should be properly trained and shown where to properly document the time-out. Justification

AFT Task 1

6

Communication in the perioperative environment is a requirement for safety. A patient’s life is at hand during a surgical procedure and one wrong mistake can be fatal. The patient is also typically sedated during surgical procedures and does not have the autonomy to speak up for themselves. It is the members of the procedure room's responsibility to communicate effectively with the patient. Policies and standards are set in place by hospitals for the safety of the patients. Hodgen (2017) stated “Surgical checklists and time-out procedures have promoted a standardized, "all-hands" approach to addressing some of the challenges to effective communication in the perioperative environment. There are many challenges within the perioperative environment. The patient starts in pre-op and then transfers to the operating room. Once the procedure is finished the patient is transferred to the post-anesthesia care unit. Communication and handing off a report between each patient are key for the patient's safety and making sure that everyone is aware and understands what is/has happened.

AFT Task 1

7 References

Hodgen. (2017, January). Communication in the Operating Room Setting. Retrieved December 02, 2020, from https://pubmed.ncbi.nlm.nih.gov/27935774/

The Joint Commission E-dition. (n.d.). Retrieved December 08, 2020, from https://edition.jcrinc.com/MainContent.aspx...