Essay Sample on Nightingale Comm. Hosp. Accreditation: Quality, Safety & Cost Efficiency

Introduction

The task at hand revolves around the accreditation of Nightingale Community Hospital. It can be understood that accreditation touches on the act of granting recognition to an institution that maintains suitable standards. As such, the institution will be considered to be operating under the required practices, where such aspects as quality, safety, and cost efficiency are highly regarded and adhered to. For the case of Nightingale Community Hospital, being a healthcare institution, it operates under the working standards and stipulations of Joint Commission Standards, which ensures that healthcare institutions assure quality to its stakeholders. Based on the attached accreditation audit case study, there is the exploration of the compliance status of Nightingale Community Hospital with respect to communication, the focus area of Joint Commission Standards. Following the compliance status, there is the development of a corrective action plan that would ensure compliance to information management standards set by Joint Commission Standard. In the end, there is the justification why the review area, information management, is important to the hospital.

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Information management is concerned with the measures of ensuring that all the healthcare information in the jurisdiction of the hospital is handled well. The information ranges from those of the individual patients from the time they are admitted to the hospital to the time they are discharged, alongside those of inpatient and outpatient individuals. The information is kept well to ensure that all the data as the patent is being attended to is tracked. They can also be used for future references in the event they are needed or where the patients develop complications related to the previous ones that have been recorded. Information management, further, when kept effectively, is an indication of the responsibility nature of the healthcare institution where it values every transactions and services offered to its stakeholders, and more especially the patients.

Figure 1: Joint Commission Standards on Information Management

It can be established that Nightingale Community Hospital offers treatment and care services to its patients. As such, it is obliged to keep the records of patients attended to in every day basis. Its compliance status when it comes to information management can be assessed in its operation under the three Joint Commission Standards that when effectively complied will amount to the institution being considered absolutely competent and credible. Thus, three Joint Commission Standards need to be adhered to by the institution when it comes to how it handles and manages its information concerning the patient transactions undertaken. The first one labelled IM.02.02.01. The standard is described that the hospital effectively and proficiently manages the collection of health information. As such, the standard points out an aspect of responsibility and accountability. It alludes to the act of hospital being fully in charge of the collection of patient information, including those of patient admission, labelling and identification of patients to avoid errors and improve efficiency and accuracy, as well as the use of full names of such items as drugs. It happens that information in the healthcare institution also includes the communication between healthcare professionals, manifested in such instances as patient referrals, where a note from one healthcare practitioner is transferred to another one via a patient. The use of abbreviations in such instances can be dangerous since they can be misunderstood or misinterpreted leading to medication errors. In the end, danger is posed to the patient on the receiving end of poor and wrongful medication practices.

Secondly, there is the Joint Commission Standard known as RC.01.01.01. It is described that the hospital maintains a complete as well as accurate medical records for every individual patient. As such, the standard is spearheaded to enduring that part from keeping the patient information, they too need to be complete and accurate. In the process, being complete will ensure that the progress of the patient during the treatment until full recuperation is documented for future references. The accuracy of the data will too ensure that the subsequent stages as the patients are being attended are done with respect to preceding steps, ensuring that all the processes of patient treatment are attached together in a continuum with the medication stages following one another as required. The accuracy of information will also facilitate effective patient attendance by a different medical officer as the previous one who can be occupied in different duties. Thus, proficiency will be paramount in the healthcare institution.

Finally, there is the Joint Commission Standard known as RC.01.04.01. It is described that the hospital audits all of its medical records (Joint Commission Resources & Joint Commission International, 2012). The process of auditing serves as an examination to determine whether the activities that have been done before have been compliant with the set standards. Thus, the activities are assessed against the set standards. A rating or scale is then assigned to the institution indicating whether it has been following the set rules in its activities. In the event it has not been compliant in keeping the records, it will take the necessary steps to ensure it is operating in the manner required by the set standards of Joint Commission Standards. however, if it has been complaint, it will serve as an indication of rightful operation as per the set standards.

With respect to the compliance status of Nightingale Community Hospital to the above three Joint Commission Standards on information management, it has been undertaking some practices aimed at promoting compliance. To start with, the institution has been keeping complete and accurate information regarding the admission of the patient. The activity is in adherence to Joint Commission Standard labelled RC.01.01.01, which requires that the hospital maintain complete and accurate information and medical records for each individual (Joint Commission Resources & Joint Commission International, 2012). The details in the patient admission capture all the data required of patients. They include the name of the healthcare practitioner attending to the patient, the name of any allergies present, as well as whether the individual will serve as an inpatient, observation, tele, ICU, or medical surgery. In such a scenario, the individual patient data on the nature of medication and the related details are well captured.

There are also such data surrounding consults or education, with such details as cardiologist and the reason for visiting him, the reason for hospitalization, whether the patient undergoes cardiac rehab, nutritional consult, and whether smoking cessation education or case management consult is required, and if none of the above, a space for filling in any other consult is provided. The data details on the reasons for medical attention requirement by the patient. There are also such details captured in the sheet as diet requirements, activities to be undertaken by the patient to act as corrective measures, vital signs with pulse oximetry, medications, labs or tests, date and time of admission, signature and name of the admission authority (Joint Commission Resources & Joint Commission International, 2012). There are also specific details under the above ones that specifically addresses the patient. In the end, the patient will be holistically understood following admission data recorded.

Besides, after the admission of patients to the Nightingale Community Hospital, they are labelled and identified to ease their attendance by the healthcare professionals. the process of patient identification should be done accurately to ensure that they are well taken through the medication procedures that they were admitted to (Joint Commission Resources & Joint Commission International, 2012). Thus, patient identification should be as accurate as possible, and the identification errors should be minimized to the lowest terms possible (Joint Commission Resources, 2011). However, in Nightingale Community Hospital, there have been instances of patient identification errors. From the audit conducted the information management with regard to the improving the accuracy of patient identification was violated to some extent. In the previous year, the patient identification errors occurred eighteen time while in the current year, the number of patient identification errors rose to forty two times. As such, the Joint Management Standard regarding information management, labelled RC.01.01.01 was not fully complied with. The standard has it that the hospital should maintain complete and accurate medical records for each individual, failure to which leads to noncompliance as already recorded in the institution. It can be observed that patient identification errors rise yearly, an indication of the deteriorating practice of patient identification and adherence to information management standards in place. Hence, it can be concluded that Nightingale Community Hospital is non-compliant to Joint Commission Standard labelled RC.01.01.01 requiring the hospital to maintain complete and accurate medical records for every patient.

Moreover, there is an aspect surrounding the use of unacceptable abbreviations. In such a case, the use of unacceptable abbreviations is highly discouraged in the healthcare institutions, as stipulated by the Joint Commission Standards labelled RC.01.01.01, which requires a complete keeping of medical records by a healthcare institution (Joint Commission Resources, 2011). The abbreviations used by healthcare professionals while communicating in writing, mostly observed when they refer to drugs of specific actions to be undertaken by their workplace partners, amount to incomplete medical records prone to misinterpretation and subsequent wrongful medications that risk the health of patients being attended to. Ideally, to curb the above results, the healthcare professionals have enacted the patient care policy that bans the use of prohibited abbreviations. There adherence leads to the prevention of errors. The intended meaning of the abbreviations might be unclear, hence the need to contact the ordering practitioners for clarification. An example of prohibited abbreviations include:

As can be observed above, the meaning of abbreviations can be misinterpreted to other words with similar abbreviations, leading to errors that can potentially harm the patients on the receiving end of medication.

Following the conduction of audit regarding the usage of prohibited abbreviations in Nightingale Community Hospital from January to December, it was discovered that there was still the use of 99.6% of prohibited abbreviations in the facility. The abbreviations that were mostly used in the institution include qd, x3d, ms04, sc, u, s, and x.0. As such, it can be observed that there was a noncompliance to the Joint Commission Standard RC.01.01.01 on the maintenance of complete medical records (Joint Commission, 2016). Therefore, medica...