AFT2 Task 1 Page 2
A. Compliance Status
Communication Joint Commission addresses the UP 01.01.01, UP 01.02.01, and 01.03.01 laws. Under the UP 01.01.01 there are three compliance codes the Nightingale Community Hospital needs to be following. The hospital follows the first code to implement a preprocedural process to verify the correct procedure for the correct patient at the correct site. It is found in the Site Identification and Verification under the Preoperative/Preprocedural Verification Process section. The second code under the law is to identify items that must be available for the procedure and use a standardized list to verify their availability. The hospital follows this code in the preprocedure hand-off. It is a list of information they for the patient. The third code is to match the items that are to be available in the procedure area to the patient. The hospital follows this code under the Patient, Procedure and Site Verification in the Site Identification and Verification.
The UP 01.02.01 has 5 different codes the hospital needs to be incompliance with. The first and second codes about marking the site before surgery are found under the Marking the Operative/Invasive Site in the Site Identification and Verification policy. The hospital is not in compliance with the third code stating that the procedure site needs to be marked by a licensed independent practioner (PA, or APRN). Currently the policy states the patient will mark the site and if there is an issue, the doctor will come mark the site. The method of marking the site and the type of mark is unambiguous and is used consistently throughout the hospital follows this code. Under the Marking the Operative/Invasive Site it explains the type of marker should be permanent and the different lettering for each type of surgery. The fifth code about written alternative process in place for patients who refuse the site marking is also found in the Marking the Operative/Invasive site.
The UP 01.03.01 code states a time out needs to be conducted immediately prior to beginning the procedure. The time-out policy of the hospital does comply with the following characteristics mentioned in the Time-Out Procedure. The hospital policy does not mention when two or more procedures are being performed. The policy does comply to the minimum of stating the patient identity, site and procedure done along with the documentation of completion of the time-out. These codes are mentioned in the Time-Out Procedure.
The hospital policy complies with the Joint Commission codes of communication except for two codes. Who will mark the site and time-out procedure when there are two procedures being performed on the same patient is not mentioned in the policy. For the hospital to be accredited by the Joint Commission, a new action plan will be put into action for the procedure site to be marked by a licensed independent practitioner. Currently, the hospital policy states the patient will mark ...