Aft2 Task 1

Nightingale Community Hospital is a 180-bed, acute care, not-for-profit, community hospital.
They provide services in general medical/surgical services, critical care & emergency services,
oncology, cardiology, cardiology, telemetry care, vascular lab, neuroscience unit, orthopedics,
imaging services, obstetrics, level II nursing, and endoscopy and surgery. Nightingale
Community Hospital is currently Joint Commission accredited. Overall, the hospital was found
to be compliant with the elements of the national patient safety goals; out of compliance in only
two areas. Upon the review of the National Patient Safety Goals for conducting a pre-procedure
verification process, the elements of performance were reviewed, and the hospital was in
complete compliance. Nightingale Community Hospital currently has a site identification and
verification policy. This policy includes all the measurements taken to prevent wrong-site,
wrong-procedure, and wrong-person surgery.
During the review of the National Patient Safety Goals for marking the procedure site,
Nightingale Community Hospital wasn’t in compliance with the procedure being marked by a
licensed independent practitioner who is ultimately accountable for the procedure and will be the
present when the procedure is performed. In limited circumstances, the licensed independent
practitioner may delegate site marking to an individual who is permitted by the organization to
participate in the procedure and meet certain qualifications, which are listed in the joint
commission standards. The remainder of the elements of performance regarding the marking of
the procedure site can be found in the hospital’s site identification and verification policy.
Regarding the National Patient Safety Goals for timeouts being performed prior to a procedure,
Nightingale Community Hospital was found non-compliant. The “Time-Out Procedure” portion
of the company’s policy included conducting a time-out immediately before starting the invasive
procedure or making the incision. The time-out also included all of the characteristics listed in
the elements of performance. However, the policy and pre-procedure section doesn’t include a
time-out when two or more procedures are being performed on the same patient and the person
performing the procedure changes.
Nightingale Community Hospital is out of compliance in areas 01.02.01 and 01.03.01. To rectify
these issues, a corrective action plan, as follows, should be implemented. Regarding the
procedure site being marked by a licensed independent practitioner, the quality nurse coordinator
should meet with the company’s policy and forms committee to update the policy that states “all
patients undergoing operative or invasive procedures will identify and mark the
operative/invasive site prior to the procedure will applicable”. The coordinator should also
review compliance issues with the committee, and discuss the changes that are needed to be
made going forward. After identifying that a licensed independent practitioner (or an individual
who is permitted by the organization to participate in the procedure) is needed within the policy,
changes need to be reviewed with the committee for approval. Once approved, the changes need
to be presented at the company’s next monthly staff meeting. To verify understanding, I suggest
a group activity, such as an interactive game, that includes testing the knowledge of the
employees. To monitor compliance thereafter, an audit should be created that includes the
physician’s consent, which will reflect the involvement and knowledge of the correct protocol
when performing a procedure. The coordinator’s responsibilities afterwards should be to
continuously educate staff on policy changes, and spot monitor compliance to ensure
Nightingale’s compliance statistics remain 95% or greater. In regards to a time-out when two or
more procedures are being performed on the same patient, the corrective action plan should be
similar. The coordinator should meet with the policy committee and review compliance issues.
Changes made to the company’s Time-Out Procedure section should be reviewed and discussed.
After making changes, they should be reviewed by the policy committee for approval and/or
revisions. Once approved, modifications will be presented to staff at the medical executive
meeting. Tracking the time-out trend will be done monthly using the universal protocol (as seen
on the bar graph). And adding a section to the current pre-procedure policy specifically for when
two or more procedures are being performed at the hospital should be the ultimate corrective
action for that element of performance.
Communication is a critical component in all businesses, especially healthcare. Communication

is a fundamental clinical skill that, if performed competently and efficiently, facilitates the
establishment of a relationship of trust between the medical staff and the patient-customer, a
truly therapeutic alliance (2008). In a hospital setting, communication helps to deliver clinically
correct information, which in turn, prevents serious errors in the healthcare field, such as
medication errors, billing issues, and patient deaths. Effective communication promotes patient
protection, company revenue, and increases productivity for day to day operations. Efficient
communication also builds trust between an organization and its’ employees. Employers are
more likely to retain employees if they provide a safe, efficient work environment.
Communication provides this kind of efficiency.
References
Health Thomas R K. A Pratictioner's Guide. New York: Springer; 2008. Services Marketing.

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Nightingale Community Hospital is a 180-bed, acute care, not-for-profit, community hospital.

Communication is a critical component in all businesses, especially healthcare. Communication

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