KCM1 - Task 3 - Task 3 PDF

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Task 3...

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KCM1 - Task 3 CONFIDENT Western Governors University

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Table of Contents Intro………………………………………………………………………………………… 3 A: Patient Tracer Summary …………………………………………………………………3 A1: Evaluation ……………………………………………………………………………. 4 A2: Plan …………………………………………………………………………………… 5 References ………………………………………………………………………………… 7

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Intro I will explain about the tracer procedure to follow a patient's care so as to assess the healthcare facility system of furnishing care, aid and help for a preparedness review/audit. The Joint Commission (TJC) states that “tracers allow surveyors to identify performance issues in one or more steps of the process, or interfaces between processes” (TJC, 2018). There are three main types of tracers used on-site to inspect a healthcare facility by TJC. Those three tracers are: individual, system and accreditation program-specific. A: Patient Tracer Summary A tracer was performed at Nightingale Community Hospital on a patient who recently visited the facility and services performed. The sequence of care/services department included Surgical Nursing Unit, Radiology, the OR, PACU and currently the Surgical Nsg Unit. The patient was identified as a 67 year old female scheduled for a laparoscopic hysterectomy however due to excessive bleeding prior to hospitalization the surgery was changed to an open procedure. 7 days later the patient presented with fever and drainage and was readmitted for probable wound infection due to the operation. Five days later the patient underwent another surgery to attend the abscess that developed from her previous operation and a central line was inserted for long-term antibiotics. We are anticipating for the patient to be discharged to the spouse along with home health providing supervision of the antibiotic therapy.

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A1: Evaluation While reviewing the surgical patient tracer the main deficiency identified was the admission assessment regarding the history & physical not achieved within 24 hours of admission (>72 hours). Per Joint Commission, "a history and physical (H & P) is completed within 30 days prior to inpatient admission or registration of the patient, an update is required within 24 hours after the patient physically arrives for admission but prior to surgery or a procedure requiring anesthesia services'' (TJC, 2018). The purpose of an H & P is to verify if there are any underlying issues that would affect the patient's planned surgery, such as a medication allergy, a blood disorder, or any condition that can prompt an issue during the surgery. The tracer tip section states that by the end of the shift the day the patient is admitted the nurse should review the admission history (including the H & P), inquire about any gaps or blanks, examine the med reconciliation process and request the care plan. Per the Joint Commission standard PC.01.02.03, “The hospital assesses and reassesses the patient and his or her condition according to defined time frames” (TJC, 2020). Within this standard there are 6 elements of performance, which one is obvious that the patient must receive a physical check-up no more than 30 days before or else 24 hours within admission, as well as if there are any documentation changes it must be completed within 24 hours prior to the surgery (TJC, 2020). There were multiple healthcare associates that were providing care that could have updated the chart prior to the end of the shift however it was not achieved just before 72 hours which is an infraction of the Joint Commission standard of care. A2: Plan Nightingale Community Hospital will need to develop a corrective action plan to address the TJC violation of PC.01.02.03 standard, performance elements one through six. This plan will

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need to be enforced within a week of the finding by the hospital. Quality should be looped in by the Director of Nursing (DON) to make sure that there are up-to-date policies and procedures in place so that all medical staff can be held accountable. Quality will also establish the updated learning and required education training. IT will be responsible to make sure that the education is sent out to all staff via email and their education portal with the appropriate deadline, this will also make sure that it is communicated to all nurses. The DON will make sure to hold daily safety huddles with the staff on the sequence of Care/Service departments to make sure that all staff are efficient and knowledgeable of the new updated policies and procedures along with the required education training course. In order to make sure that all members of the staff are trained the hospital should make this an annual training requirement. In order to make sure that the policy and procedures are followed and effective we will need to be tracking incidents and following-up with the multiple departments and should be handled by the DON since that position is over all nursing staff for the organization. As a hospital we will perform a cost benefit investigation to form a corrective action plan that is cost effective, set reasonable deadlines, and then assess and monitor the progress. Per the Joint Commission "accountability measures are quality measures that meet four criteria designed to identify measures that produce the greatest positive impact on patient outcomes when hospitals demonstrate improvement: Research, Proximity, Accuracy, and Adverse effects" (TJC, 2018). In order to monitor our progress we need to hold the staff to the following: screening and assessments, training and competency, rounding on patients and departments, and tracers. The proper method for these deficiency is to perform regulatory audits along with an assessment of actions to stay within the rules. Nightingale Community Hospital can use the Intracycle

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Monitoring (ICM) process to help with continuous standards of compliance. In order to use the Focused Standards Assessment (FSA) which is a component of ICM tool the hospital will need to evaluate and score the elements of performance (EP) compliance with the standards. The FSA tool uses historical data for future reference. We can use this to reinstate the standard to full compliance. The FSA tool "focuses on self-assessment on a minimum subset of risk-related standards (about 45% to 60% of total applicable standards) rather than all standards" (TJC, 2020).

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References The Joint Commission (2018). Available from Tracer methodology The Joint Commission E-dition. (2020). Retrieved from Joint Commission Resources Portal...