Corrective Action Plan for Nightingale Community Hospital - Essay Example

"Corrective Action Plan for Nightingale Community Hospital" is a perfect example of a paper on the health system. This paper examines Nightingale Community Hospital's (NCH) use of a tracer methodology to track a patient and determine patients' care issues that do not comply with Joint Commission standards. This paper also creates a corrective action plan for NCH to handle the patient care enhancement needs to abide by the Joint Commission standards.a. Summary of the Tracer Patient The tracer patient is a sixty-seven-year-old woman who was due to undertake a laparoscopic hysterectomy at NCH.

Five weeks before her scheduled hospitalization, she suffered excessive bleeding and was admitted to NCH for open hysterectomy surgery. The patient was later discharged but started developing fever and drainage problems, and the patient had to be re-admitted seven days ago for a likely post-operative infection. Five days before that, she had an extra surgery to treat the abscess that had developed. Two days after re-admission, it became mandatory for the patient to undertake another operation to clear up the drainage and insert a central line for administering IV antibiotics.

The patient is scheduled for discharge to her home with the help of her spouse and home health services offering supervision of antibiotic treatment. In reviewing the patient’s Surgical Tracer Worksheet in the patient admission evaluation section, the notes indicate that the patient’s history and physical assessment were not made within twenty-four hours of admission. The patient's tracer suggests that the admission assessment was done after seventy-two hours after admission. NCH Surgery Procedure Policy indicates that an initial nursing assessment should be done within twenty-four hours of admission.

This is important in helping the nurse on duty to know and identify the patient's condition and challenges. In the Tracer Worksheet, the Tracer Tips column indicates that this assessment should be done before the end of a shift upon patient admission. The Joint Commission standard PC.01.02.03 on the provision of care services suggests that a hospital should evaluate and re-evaluate the patient’s condition as per its defined timeframes. The timeframe for NCH is twenty-four hours. In the performance elements of PC.01.02.

03, element number four highlights that a patient should have a medical history and physical exams are done thirty days before admission or within twenty-four hours after registration or in-patient admittance, but before surgery necessitating anesthesia services. The performance element five under this standard indicates that a therapeutic history and physical exams should be made in thirty days preceding registration or in-patient admittance. Also, an updated record of any variations in the patient's situation should be done within twenty-four hours after check-in or in-patient admittance but preceding a surgery needing anesthesia services.

Performance element number six under the same Joint Commission standards indicates that a registered nurse should do a nursing evaluation within twenty-four hours after a patient’s in-patient admittance. Because of a lack of patient evaluation done within twenty-four hours, the patient’s tracer worksheet highlights an evident violation of the JCAHO standards. Also, the tracer highlights an internal breach of protocol whereby crucial information concerning the patient within the first twenty-four hours of admittance was not captured, given, or notated.

The tracer worksheet indicates a sequence of care between the PACU nurse, surgical nursing unit nurse, operation recovery nurse, and radiology nurse. They did not prioritize the admission evaluation until after seventy-two hours of the patients’ admittance. b. Corrective Action Plan The Compliance and Training departments will meet in one week to evaluate the present training criteria, methods, policies, and protocols of the nursing staff, mostly concerning admission assessment completion, as indicated in the patient tracer worksheet.

NCH surgery policy processes are compliant with JCAHO standards, but the NCH nursing staff are not following the policies and procedures. Therefore, in every point of care that a patient will undergo, the staff will be mandated to sign the patient tracer worksheet to confirm that all the Tracer Tips are adhered to and met. The training department will also organize refresher training for nursing staff in two weeks relating to the PC.01.02.03 standard. Similarly, every hospital room will have a poster hanged on the wall that highlights all the elements of the performance required of the nursing staff as per JCAHO standards.

The IT and the Compliance Department will meet for two weeks to execute a mandatory admission evaluation flagging on the patient’s EMR. On-screen Pop-ups will appear instructing the completion of patient assessment within twenty-four hours of admission. This information will be inputted by the nurse in charge in the patient's computer file and sign the tracer worksheet to confirm compliance. After twenty-four hours elapses without an initial patient assessment being done, a system report together with a list of the nursing staff who handled the patient's file since admission will be sent directly to the nursing management for reprimand for non-compliance.

This will be done to create a level of responsibility for the nursing staff part. Evaluations on compliance with these standards will be done weekly by the Chief Nursing Officer based on the system-generated reports received.In conclusion, this paper has adequately discussed NCH tracer patient care issues, and a corrective action plan was created for NCH to handle the patient care enhancement needs to comply with the Joint Commission standards.