Executive Summary for Joint Commission Standards Compliance

March 10, 2016

RAFT Task 1

Executive Summary for Joint Commission Standards Compliance

Nightingale Community Hospital provides leadership in quality health services. We also provide compassionate and cost-effective service in the lines of treatment and prevention. Our vision is to be the hospital of choice for patients, employees, physicians, volunteers, and the community. Nightingale has set standards that help the hospital stay in compliance with Joint Commission. There are four compliance areas; information management, medication management, communication, and infection control. These four areas focus on patient care, patient safety, and the effectiveness on the policies that have been put in place. I have chosen Information Management as the focus area.

IM.02.02.01 The hospital effectively manages the collection of health information. Joint Commission provides three Elements of Performance (EPs). The three EPs include: The hospital uses uniform data sets to standardize data collection throughout the hospital. The hospital uses standardized terminology, definitions, abbreviations, acronyms, symbols, and dose designations. The hospital follows its list of prohibited abbreviations, acronyms, symbols, and dose designations. (The Joint Commission E-dition).

Nightingale Community Hospital, the Order form is consistent and contains significant patient information that is collected for the best possible care of the patients. The form is reviewed on a regular basis to guarantee that critical data points are included the collection process. On all orders, there is one piece of critical information that should be included, the chief complaint. The second EPs, the hospital uses standardized terminology, definitions, abbreviations, acronyms, symbols, and dose designations (The Joint Commission E-dition). The third EPs, addresses whether the hospital is following the list of prohibited abbreviations, acronyms, symbols, or dose designations.  On the Safety Report for Nightingale Community Hospital, the National Patient Safety Goal Data (NPSG) shows that the hospital was not in compliance. From January to December the percentage rate was 99.6% compliant for unacceptable abbreviations. Nightingale Community Hospital needs to strive for 100%. During the months of January to December there were five abbreviations that were used (qd, x3d, sc, u,). ‘U’ had an increase from 17% to 63%.  

Nightingale Community Hospital will provide an internal compliance monitoring team and investigate why the errors are being made and will monitor for reoccurrences. The compliance team will do audits and determine when the prohibited abbreviations are being used. The results will show if the usage of the prohibited abbreviations are coming from a specific person or department. When errors are made they will be logged immediately along with the action that was taken. In order to make sure that hospital staff is on the same page the hospital will send out an email with the updated terms to all employees and will also post it on the hospital intranet. The staff will also identify the terms that are used commonly, and identify the terms that are confusing. The hospital will then place the confusing terms on a ‘Risky List’ or a ‘Do Not Use List’. Training and education will be provided for the health care workers. The training and education class will start immediately at various times of the day throughout a two week time span so that all shifts have the opportunity to attend.