JI

Upon completion of a thorough review of the previous Joint Commission survey and the current policies and practices of Nightingale Community Hospital, substantial changes must be implemented to assure compliance. The primary focus will be enhancing communication to ensure the safety of all patients.
The approach to augment communication is multifaceted. First, policies must be revised to outline specific steps that must be completed on all patients that are deemed at risk. A second approach will be to revamp the abilities of the electronic medical record to document how risk has been minimized. The third tactic will be to educate the interdisciplinary team on the changes in practice that will be implemented. Lastly, Nightingale Community Hospital will develop an auditing process to assure compliance and track progress.
Policy Revision
Currently, Nightingale Community Hospital has a policy about Patient, Procedure and Site Verification that must amended. Under the heading of Preoperative/Preprocedure Verification Process, additional instructions must be added to facilitate responsible authentication. Occurrence of verification is clearly outlined; however, the process of what constitutes verification is not addressed in sufficient detail. Verification of a patient must include two unique identifiers; patient full name and date of birth. Furthermore, acknowledgement of what the surgical procedure is must be noted. Ideally, the patient should provide this information or caregiver if the patient is not able to communicate. If the patient or caregiver is not able to provide this information, a licensed medical professional must review the medical record to assure accuracy. The physician will also review and note the procedure and location. If the information is deemed inaccurate at any point, the process must be repeated.
Site Identification and Verification policy refers to marking