Introduction
The outcome of the treatment process in health facilities is dependent on several factors among which is the safety of the facility. There is a need to ensure that all the systems and facilities in the health facilities are safe to enhance the treatment procedures, services delivered and the quality of care. The principles behind the accreditation process are very influential to achieving the status described above. The purpose of the accreditation process is to ensure that the health facilities can not only identify but also formulate resolutions for the problems identified. The accreditation process also aims to inspire the health facilities to improve the quality of care and safety in the delivery of services.
Nightingale Community Hospital is one of the many health facilities that offer health services. Among its core values is safety, and element that is emphasized in the accreditation process. In pursuit of safety, the Nightingale Community Hospital has instituted various measures to ensure that its systems are safe, and that they enhance the quality of care. The accreditation audit will analyze the results of various surveys, records of audits already performed, e-mails, and trends to determine whether the Nightingale Community Hospital is in compliance with the regulations and healthcare statutes that are relevant in the industry in which it operates.
Current Compliance Status of Nightingale Community Hospital
There are numerous variables to be used in determining the current compliance status of Nightingale Community Hospital. One of these variables is the degree of preparedness in the event of a fire in the hospital. The hospital is required to perform periodic fire drills. The precise standard is one fire drill for every shift per quarter. The first quarter of the year was between January and March. The hospital did not comply with the standard on fire drills. There was no fire drill performed on the third shift for this quarter.
The hospital required with the minimum standard for fire drills during all the shifts in the second quarter of the year. The third quarter of the year was between the months of July and September. The minimum standard for fire drills were achieved in the first and second shifts. There was noncompliance in the third shift during this quarter. This was the case in the second shift of the fourth quarter during which no fire drill was performed. There was at least one shift in which no fire drills were performed in three of the four quarters of the year. This is evidence of noncompliance with fire safety and preparedness.
The compliance status of Nightingale Community Hospital was also subject to audits by The Joint Commission Standards. Its results show noncompliance in several key areas that have a direct and indirect impact on the safety and quality of care. Some of the recurring compliance issues noted during the audit by the Joint Commission Standards was the lack of promptness in the documentation. This resulted in overtime which further resulted in low employee morale. Another reoccurring compliance issue was the late authentication of verbal orders. Ideally, such orders should be authenticated in 48 hours.
Another compliance issue was the use of abbreviations which are prohibited when making progress notes, physician orders, and nursing notes. This transgression has a direct impact on the delivery and quality of care. The auditors also found issues in the environment of care. For instance, the presence of clutter in the hallways, particularly the presence of surgical equipment and stretchers in the hallways was a common compliance issue. Even though the impact on life safety is indirect, its cumulative effect with other compliance issues can affect the provision of care negatively.
Trends Evident in the Accreditation Audit Case Study
There is a need to determine whether the compliance issues highlighted in the current accreditation audits are emergent issues or are part of a trend in the health facility. The survey performed in the health facility to years ago offers a baseline upon which some of the qualitative data can be evaluated for trends. One of the trends noted was the lack of documentation in the delivery of care. There is a need to make notes and make a record of all the patient information in the relevant places to help inform other members of the healthcare team and also aid in decision-making. However, the lack of documentation is becoming a trend in the health facility.
Trends are not just denoted by their occurrence over time, but also by the occurrence of certain events in different places in the same manner. In this respect, other trends witnessed in the hospital relate to the noncompliance of fire drills. As highlighted previously, the health facility did not comply with the minimum standards for fire drills in certain shift. Commission standards. Part of this issue also involves the placement of other items near firefighting equipment, for instance, the placement of stretchers and other equipment near the fire extinguishers.
Performance Improvement Standard
The performance of the staff is dependent on among other factors their adequacy and their productivity. When determining the compliance of employees with the performance standards, there is need consider how performance is measured in such a scenario, and the adequacy of the employees for the task to be measured or the given financial expectation. This criteria will be employed in the accreditation of the improvement of the staff performance at the health facility.
Staffing Patterns of the Patient Care Unit
There was in interest in understanding the relationship between the prevalence of falls and the nursing care hours and the overtime hours. This is to determine whether an increase in the number of nursing care hours had any effect on the prevalence of falls. In the 4-E ward, the analysis of data shown that the falls prevalence did not have a linear relationship with the nurse performance. This implies that increasing the number of nursing care hours for every patient day does will not necessarily translate into a reduction in falls prevalence. This was the case in the two other wards considered during the tracking of data. It is for this reason that the audit recommendations resulted to the use of the Root Cause Analysis in determining the interventions to reduce the falls prevalence.
Staffing Plan to Reduce the Prevalence of Falls in the Patient Care Unit
It is an earnest endeavor by all health facilities to reduce the number of patient falls in the inpatient wards. This is because patient falls affect the outcomes of the treatment process by either aggravating the initial injuries or causing new injuries. The hospital has established targets that exemplify the desire of the hospital to reduce the number of falls. For instance, the following data is specific to ward 4-East.
Figure 1 showing the Overview of Patient Falls in Ward 4-E
The data above shows the number of patient falls per 1000 patient days in Ward 4-E for an entire year. When compared against the planned targets of the hospital where number of patient falls per 1000 patient days was expected at 3.21, the data presented shows that this target was achieved in only three of the twelve months of the year. With regards to the number of falls that resulted in injuries, the hospital had targeted at 0.62. When the targets are compared against the actual results, it is evident that the targeted results were achieved on five months of the twelve months for which the data was collected.
Figure 2 showing the Overview of Patient Falls in the Hospital
Hospital-wide data shows that the targets for the number of falls with injury were achieved on seven months of the twelve months for which the data was tracked. The targets for the number of patient falls for every 1000 inpatient days were achieved on five months of the twelve months for which the data was tracked. Based on the data, evidence shows that the problem is not in the targeting of the hospital but rather in the implementation of modalities to achieve the targets. Any viable solution should present an implementation strategy that addresses the causes of the falls and also provides a way to preempt the falls.
In this regard, the hospital should introduce hourly rounding by the nurses in the various wards in the hospital. Dyck, Thiele, Kebicz, Klassen & Erenberg (2013) find that when implemented properly, hourly rounding is effective in reducing the number of falls in the inpatient wards. Mitchell, Lavenberg, Trotta & Umscheid (2014) argue that the effectiveness is attributed to the increase in nurse responsiveness to the needs of the patients.
References
Dyck, D., Thiele, T., Kebicz, R., Klassen, M. and Erenberg, C. (2013). Hourly rounding for falls prevention: A change initiative. Creative Nurse, 19(3): 153-158.
Mitchell, M., Lavenberg, J., Trotta, R. and Umscheid, C. (2014). Hourly Rounding to Improve Nursing Responsiveness: A Systematic Review. Journal of Nursing Administration. 44(9): 46+2-472.
