Executive Summary Joint Commission Standards Compliance

Prepared by: AK- Joint Commission Priority Focus Area: Communication RAFT Task 1

The Joint Commission Priority Focus area for Nightnigale included the four areas: • • • • Information Management Medication Management Infection Control Communication

All these priorities focus on the national patients safety goal as the most important in patient management and treatment, and guide the hospitals toward appropriate policies and protocols to follow and to minimize any possible mistakes or patients harm. I choose the priority focus area of Communication to discuss the current compliance status of our organization concentrating on the standards, which did not meet the Joint
It is much less by medical residents and extremely rare by nursing staff b. Patient volume have a significant effect on the percentage of unacceptable abbreviations c. Most of the unacceptable abbreviation was noticed on paper medical records.

4. Time Out: Goal 100%. • Time out as a standard will make sure of appropriate treatments and surgical procedures to be delivered to the right patients. The importance of this policy was magnified after the national statistics suggested a significant increase in specifically surgical procedures mistakes. Our institution compliance range between 90% in January to 100% in December. Despite all departments noticeable improvement in this element, we still identify some non compliance due to: a. Number of areas the patients move to before and after procedures. b. Number of staff that transfer patient care to each other, which lead to some miscommunication and then noncompliance. c. Lack of following Time Out procedure when supervisors are not available: suggesting that staff lack enough education and understanding for the reason behind this policy.

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Corrective Action Plan: Understanding some of the above reasoning will lead us to a significant improvement in our compliance with the Joint Commission standards. In further discussion with medical staff, nursing representatives, pharmacy and laboratory committees, some ideas were suggested to correct the leading causes for non-compliance.