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AFT2 Task 4:

Western Governors University Accreditation Audit Task 4

AFT2 Task 4:

Compliance Status The Joint Commission regulatory standards are known industry wide as the gold standard in healthcare. Nightingale hospital strives to provide the highest quality care to the population it serves; therefore, Nightingale is dedicated to meeting the requirements set fourth by the Joint Commission. In anticipation of an upcoming Joint Commission survey we have compiled this document which highlights areas of compliance and areas of non-compliance identified through the FSA findings. The Joint Commission Accreditation Requirements contain 18 categories, they are as follows: Accreditation Participation Requirements (APR), Environment of Care (EC), Emergency Management (EM), Human Resources (HR), Infection Prevention and Control (IC), Information Management (IM), Leadership (LD), Life Safety (LS), Medication Management (MM), Medical Staff (MS), National Patient Safety Goals (NPSG) [Universal Protocol (UP)], Nursing (NR), Provision of Care, Treatment, and Services (PC), Performance Improvement (PI), Record of Care, Treatment, and Services (RC), Rights and Responsibilities of the Individual (RI), Transplant Safety (TS), and Waived Testing (WT) (The Joint Commission E-dition, Accreditation Requirements, 2020). Next, we will go through each category to identify compliance status. We will begin with the eight compliant categories then move to the ten non-compliant categories.

Compliant: Accreditation Participation Requirements (APR) Without being compliant within the APR, the organization would not be able to participate in and become accredited. Emergency Management (EM) The EM accreditation represents the organizations ability to handle an emergency event. A strong emergency readiness program ensures that our communities healthcare needs are met in disaster scenarios. Human Resources (HR) HR accreditation is key to the ability for the organization to provide the staff needed to carry out the healthcare requirements of the community.

AFT2 Task 4: Infection Prevention and Control (IC) IC accreditation is central to patient safety. It is extremely important that people feel confident in their safety, especially from Hospital Associated Infections (HAIs) within our facilities. Performance Improvement (PI) A key quality metric is the organization’s performance improvement program. Being accredited in this category represents a strong commitment to providing high quality services. Rights and Responsibilities of the Individual (RI) Accreditation in RI is key to protecting patient privacy. It is a patient right to maintain medical privacy to maintain their dignity and avoid discrimination. Transplant Safety (TS) This accreditation ensures patients that receive transplants get high quality care, communication, and outcomes. Waived Testing (WT) WT accreditation covers tests that patient perform on themselves, this accreditation ensures that patients are well equipped and informed on performing any tests they administer themselves.

Non- Compliant: Environment of Care (EC) Standards not met: EC.02.03.01, EC.02.03.03 and EC 02.05.09 (The Joint Commission E-dition, Accreditation Requirements, 2020). EC.02.03.01: Smoke wall penetrations were found on the 1st floor and 4th floor. EC.02.03.03: Fire Drill frequency did not meet requirements. EC. 02.05.09: Master Alarm panel for medical gasses not tested annually.

AFT2 Task 4: Information Management (IM) Standards not met: IM.02.02.01 (The Joint Commission E-dition, Accreditation Requirements, 2020). IM.02.02.01: Prohibited abbreviations used in 3E, 4E, ICU, and Telemetry.

Leadership (LD) Standards not met: LD.03.06.01 (The Joint Commission E-dition, Accreditation Requirements, 2020). LD.03.06.01: Focus in not on improvement on safety and quality in 3E due to complaints of overwork and low morale.

Life Safety (LS) Standards not met: LS.01.02.01, LS.03.01.20, LS.03.01.35 (The Joint Commission E-dition, Accreditation Requirements, 2020). LS.01.02.01: Interim life safety measure (ILSM) not initiated on multiple construction projects. LC.03.01.20: Clutter in hallways found in 3E, 4E, OR, and Telemetry. LC.03.01.35: Sprinkler didn’t meet 18” clearance requirement in gift shop.

Medication Management (MM) Standards not met: MM.04.01.01, MM.05.01.09 (The Joint Commission E-dition, Accreditation Requirements, 2020). MM.04.01.01: Nurse didn’t follow range order policy in 4E, Nurse couldn’t explain execution of range dose policy in ICU. MM.05.01.09: Propofol syringes unlabeled in OR and Cath lab.

AFT2 Task 4: Medical Staff (MS) Standards not met: MS.08.01.01 (The Joint Commission E-dition, Accreditation Requirements, 2020). MS.08.01.01: The Ongoing Professional Practice Evaluation (OPPE) is not up to standard.

National Patient Safety Goals (NPSG), Universal Protocol (UP) Standards not met: NPSG.03.04.01, UP.01.02.01 (The Joint Commission E-dition, Accreditation Requirements, 2020). NPSG.03.04.01: Unlabeled syringes found in OR and Cath Lab, unlabeled basins found in OR, prelabeled syringes from supplier in OR. UP.01.02.01: Surgical site not marked in OR, Biopsy site not marked in Endoscopy.

Nursing (NG) Standards not met: NG.02.02.01 (The Joint Commission E-dition, Accreditation Requirements, 2020). NG.02.02.01: Staff to patient rations are not adequate in 3E indicating a inadequate nurse staffing plan.

Provision of Care, Treatment and Services (PC) Standards not met: PC.01.02.03, PC.01.02.07, PC.03.01.03 (The Joint Commission E-dition, Accreditation Requirements, 2020). PC.01.02.03: Day of procedure reassessment missing in numerus cases in Cardiac Cath Lab, Endoscopy , and Surgery Pre-Op. PC.01.02.07: The emergency department consistently misses recording the pain assessments and reassessments. PC.03.01.03: The Endoscopy department does not have documented anesthesia plans.

AFT2 Task 4:

Record of Care, Treatment, and Services (RC) Standards not met: RC.02.03.07 (The Joint Commission E-dition, Accreditation Requirements, 2020). RC.02.03.07: PI Data, Telemetry, 3E, 4E, and the Emergency Department have not been authenticating verbal orders within 48 hours.

Non-Compliant Trends Each area where Nightingale is found non-compliant is important to correct, but there are some noticeable trends where some standards are not met spanning multiple departments. This is evidence of an overarching problem that needs to be addressed on an organization wide scale. The first such trend that was identified was the lack of authentication of verbal orders within 48 hours which is out of compliance with Record of Care, Treatment, and Services RC.02.03.07 in the Joint Commission Accreditation Requirements. This issue has been found within multiple departments facility wide, which identifies that a policy change may be required. The second trend identified was identified was the clutter found within multiple departments which brings up out of compliance with Life Safety LS.03.01.20. The clutter found within these departments may be an indicator of poor storage options, or poor room design leading to overflow and critical items being left in our hallways creating egress, tripping, and sightline safety issues. It is recommended that the Compliance department teams up with leaders from each area that these issues were found to assess the situation further in order to identify potential solutions. Policy and procedure changes may be necessary. Any changes deemed necessary will be presented to the Compliance Committee for change approval and implementation.

AFT2 Task 4:

Staffing Patterns Nightingale is dedicated to ensuring that its patients are afforded the highest quality care, in the safest environment. To support this Nightingale utilizes date from clinical/service screening indicators and human resource screening indicators to assess and continuously improve staffing effectiveness. Next, we will analyze our current staffing levels, and identify correlation between patient safety and staffing issues. As stated in the American Society of Registered Nurses article, Nurse Staffing And Patient Safety, “Nurses' vigilance at the bedside is essential to their ability to ensure patient safety. It is logical, therefore, that assigning increasing numbers of patients eventually compromises nurses' ability to provide safe care.” (Nurse Staffing And Patient Safety, 2015).

In our Staffing effectiveness report we ended up identifying some conflicting data, when looking at patient falls (4E,3E, ICU), nosocomial ulcers (4E,3E), ventilator associated pneumonia (ICU), nursing care hours (4E,3E, ICU), and overtime indicators (4E,3E, ICU) their was no overarching sign of correlation. To maintain consistency between the departments analyzed we will focus on patient falls since it was measured in each of the three departments. Upon further investigation, 3E and ICU both invested in education programs for their staff related to patient falls this year, while also maintaining consistence in staff levels within their departments which has significantly reduced patient falls in both units, from 5.57 to 5.45 in 3E and from 1.9 to .41 in the ICU. While in 4E, where no education on patient falls was offered, and staffing hours and overtime vary significantly more than in 3E and the ICU there was a significant increase in patient falls from 1.47 last year to 4.37 this year, and a correlation between nursing care hours, overtime and falls can be drawn.

The correlation drawn indicates that a modification to the staffing plan needs to take place specifically in 4E where patients are at significantly higher risk that they were previously. 4E management will review current staffing levels and analyze current overtime trends and report the information found to senior leadership.

AFT2 Task 4:

Staffing Plan As evidenced above consistent staffing levels, nursing hours, and education are key to increasing patient safety. To ensure that patient safety goals are reached it is necessary that Nightingale makes changes to their current staffing plans. It is vital that the plan focuses on creating nursing hours consistency and minimizes overtime. This can be accomplished by introducing nursing staff to patient ratios, keeping in mind that quality of care and safety are our major concerns. The ratio should allow for the nursing staff to have time to properly analyze the patients fall risk as well as other risk factors upon admittance, or within a specified time after admittance. There are different resources we can utilize for those nursing hours, we have Certified Nursing Assistants (CNAs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs). Our staffing ratios for the nursing group is 1 RN can oversee up to 3 LPNs who each oversee 2 (CNAs). Another aspect of our staffing plan that needs to be addressed is overtime. Department leaders need to reduce overtime hours, in the article Hospital Staff Nurses’ Shift Length Associated With Safety and Quality of Care the contributors state that “ Extended shift lengths were associated with higher odds of reporting poor quality and safety. Policies aimed at reducing the use of extended shifts may be advisable.” (Stimpfel & Aiken, 2013).

To provide an example of how these changes could look we will be utilizing 4E as an example due to the correlations we derived in the Staffing Patterns section. Shift Day 6AM-4PM Evening 2PM-

Charge RN 1 1

RN 3 2

LPN 9 4

CNA 12 8

12AM Night 11PM-7AM

1

1

2

4

Shift overlap is for change of shift report and an increase overlap has been allocated between the day and evening shift due to increased discharge rates between the hours of 2PM-4PM in this unit. This staffing plan meets current nurse-to-patient guidelines and affords the unit the ability to property perform safety assessments. In addition to the staff chart above there will be a rolling on-call schedule that will be in place to ensure proper staffing despite call outs. Along with the change in staffing levels, we think it prudent that all staff in 4E undergo similar education programs in recognizing safety issues with their specific patient population as the ICU and 3E. The Compliance Committee, with assistance

AFT2 Task 4: from department leaders will roll out new education plans for each unit within 90 days. We feel that this staffing allocation meets the requirements of 4E and provides adequate staffing to accomplish patient safety and care quality goals.

AFT2 Task 4:

Sources The Joint Commission E-dition, Accreditation Requirements. (2020). Retrieved June 17, 2020, from https://e-dition.jcrinc.com/MainContent.aspx

Nurse Staffing And Patient Safety. (2015). Retrieved June 26, 2020, from https://www.asrn.org/journaladvanced-practice-nursing/1403-nurse-staffing-and-patient-safety.html

Stimpfel, A. W., & Aiken, L. H. (2013). Hospital Staff Nursesʼ Shift Length Associated With Safety and Quality of Care. Journal of Nursing Care Quality, 28(2), 122-129. doi:10.1097/ncq.0b013e3182725f09...