National Patient Safety Goals in an Institution

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Table of Contents

Compliance Status
Plan for Compliance
Justification
Conclusion
References

Ensuring effective communication between care providers is essential to preserving patient safety and achieving better treatment outcomes. In the contemporary healthcare context, teams are interprofessional, meaning that care providers must promptly pass information about patients, their conditions, and diagnostic tests to prevent harm to patients and achieve treatment goals (Foronda, MacWilliams, & McArthur, 2016). Nightingale Community Hospital aims to provide patients with high-quality care and meet all the appropriate standards of patient safety. The present executive summary will seek to apply the National Patient Safety Goals to the practices of this institution to clarify its current compliance status. Then, a plan for compliance will be proposed to enhance the level of compliance and develop new practices through consistent improvement. Finally, a justification for the compliance plan will be developed based on research evidence and assessment results.

Compliance Status

The National Patient Safety Goals are a useful source of information for institutions wishing to enhance the quality of care delivered to their patient and ease the process of accreditation and certification. Nightingale Community Hospital seeks to meet all the National Patient Safety Goals to prevent harm to patients and ensure that care providers adhere to best practice recommendations in terms of patient safety. Nevertheless, there were some gaps identified as part of the assessment, which means that the current compliance status of the institution is not ideal.

First, the recommended time of reporting critical results of diagnostic tests has not been achieved consistently over the year. Although the rate of 60-minute reporting has increased from 63 percent in January to 80 percent in December, there are still gaps that must be addressed to meet the NPSG for Communication. Secondly, the NPSG recommends developing written procedures for managing critical results that include definitions, reporting chains, and time limits. However, there is no evidence of these written procedures in the Nightingale Community Hospital. The two documents provided for review concern specific manipulations, such as site identification and verification and pre-procedure handoff, but a particular policy for managing critical results of diagnostic tests is absent. Thirdly, based on past survey results, the Hospital also requires improvements to prevent the use of unacceptable abbreviations. These could be supported by the development of written reporting procedures and thus also apply to communication compliance.

Overall, the Hospital is only partly compliant with National Patient Safety Goal 2, “Improve the effectiveness of communication among caregivers.” This is evident from the lack of procedures for managing critical results of tests and diagnostic procedures, which means that the Hospital does not meet EP 1. Without written procedures, their consistent implementation throughout the institution is not possible, and thus, EP 2 is also not met. However, EP 3 is met since the organization tracks compliance with reporting standards and provides data on the hospital-wide rate of compliance. The following are the thirteen EPs for communication that are listed as compliant and non-compliant.

The presence of pre-procedure preparations to confirm that the correct procedure is applied for a relevant patient at the correct site. COMPLIANT

The identification of the items that should be available to perform procedures and the application of a standardized list to confirm their presence. The following items are not included: relevant documents, some tests are not labeled, and standardized lists are not available for every patient. COMPLIANT

Marking the items that should be available to patients in the procedure area. NON-COMPLIANT.

The identification of procedures that clarify the details of marking the incision insertion site. At least the sites should be marked if more than one location is possible for the procedure. The other requirement for marking is if the selection of another site would reduce the quality or safety of the procedure. COMPLIANT

It is important to note the procedure site before the procedure, the patient involvement is encouraged if it is possible. COMPLIANT

A licensed independent practitioner is responsible for marking the site. This practitioner should be present when the procedure is performed to ensure safety. The imperfect environment is the condition that allows the practitioner to delegate site marking to an eligible individual. The latter should be approved by the organization and has qualifications: a medical postgraduate program and licensure. NON-COMPLIANT

The site marking method and type are explicit and are consistent across the Hospital. COMPLIANT.
Those patients who refuse site marking can have an alternative, written process.

If it is technically or anatomically impossible or unreasonable to mark the site, such as mucosal surfaces or perineum, an alternative process should be in place. COMPLIANT

A time-out should be made immediately before performing the incision or beginning the invasive procedure. COMPLIANT
The time-out is standardized, includes the team members who would perform the procedure, and is conducted by the designated member of the team. NON-COMPLIANT
When two or more procedures are being performed on the same patient, and the person performing the procedure changes, perform a time-out before each procedure is initiated. NON-COMPLIANT
During the time-out, the team members are expected to have an agreement on the correct site, the procedure to be performed, and the correct patient identity. COMPLIANT
Documenting the time-out completion. COMPLIANT

Plan for Compliance

Since marking the items in the procedure area, the responsibility of licensed independent practitioners and time-out standardization are the main non-compliance points for the given organization. It is important to start the corrective plan with a detailed assessment of the reasons. In particular, the responsible person should be assigned the task of collecting relevant information and disseminating it to the hospital leadership. After the clarification of the reasons for non-compliance, the Hospital’s management should prepare a meeting to discuss these points with practitioners and identify the ways for addressing the challenges. Such a cooperative approach to resolving these problems is likely to lead to the greater involvement of care providers in their work, as well as more effective and open relationships among colleagues.

To achieve the goal of improving the coherent work of care providers and meeting the NPSG for communication, it is necessary for the Nightingale Community Hospital to make improvements. The first suggested step is to develop a policy for imperfect environments that require the assistance of another professional through delegation. Within 30 days, the Hospital should provide a detailed plan of action and requirements to choose and assign a practitioner, ensuring that he/she has licensure and a medical postgraduate program. These should be discussed and listed in a separate protocol that would include definitions, indicate the reporting chain to be implemented, and set the standard time limits to promote reporting within 60 minutes from when the results become available. This protocol should be developed by the Director of Patient Safety in line with the recommendations provided by the Joint Commission. The staff should receive information about the updates, as well as education and training necessary for them to ensure compliance within 30 days.

The second step of the plan is to enhance the monitoring of reporting times to ensure that the data are collected for each shift within 30 days. This will help to determine whether there are any individual care providers who might need additional training in reporting. By identifying the results for each shift and reviewing them weekly over 30 days, the Director will gain more insight into the situation and will thus be able to develop the controls necessary for further improvements. Accordingly, the Hospital would time-out standardization compliance through the proper and timely reporting and monitoring.

Third, it is recommended that the Hospital develops an additional policy for care provider communication that would improve marking the items that should be available to patients in the procedure area. This will help to establish the main principles of communication in the procedure area and promote overall compliance among care providers. For instance, the protocol could target the use of verbal orders or readbacks and clarify unacceptable abbreviations. These standards would assist care providers in enhancing their general communication practices, thus contributing to patient safety and service quality within 30 days.

Justification

The justification for the proposed compliance plan lies in scholarly research on the topic of care provider communication, as well as on the assessment using the NPSG. On the one hand, research suggests that effective communication between care providers is essential to patient safety. For example, Gluyas (2015) states that prompt and efficient communication is vital to cooperation, which, in turn, contributes to the prevention of medical errors and other negative consequences. Additionally, enhanced communication between care providers can contribute to patient satisfaction (Burgener, 2020). By increasing patient satisfaction, the Hospital can achieve better performance and attract new clients, thus enhancing profitability.

On the other hand, the proposed action plan will help to address the gaps in compliance identified in the assessment. Improving diagnostic test result reporting is essential for adhering to the NPSG since it is among the core goals in the Communication domain. This is because prompt diagnostic test reporting helps to prevent diagnostic errors and improve patient safety outcomes Gleason et al., 2017). Similarly, promoting the practices that enhance communication, in general, will help to ensure smooth cooperation between members of interprofessional teams as required by the NPSG. Besides identifying areas for improvement, the NPSG can also be used for goal setting, especially given the fact that the organization seeks to achieve a higher level of compliance. In this way, the recommendation to update goals for review in the Communication domain is also justified based on the results of the evaluation.

Conclusion

Overall, the summary highlights the importance of adhering to the NPSG communication standards and goals. Effective communication between care providers is necessary to enhance patient safety and outcomes. It can also help to prevent critical medical errors that stem from delays in communicating diagnostic or other medical information pertaining to patient cases. However, the assessment revealed that there are some gaps in the application of the NPSG by the Nightingale Community Hospital. More specifically, the organization must improve the reporting of diagnostic test results, limit the use of unacceptable abbreviations, and set new goals to ensure compliance with the NPSG. To address these gaps, the organization should develop additional practice protocols, add monitoring mechanisms, and update its goals for review. Implementing the proposed action plan will support the Hospital in complying with the NPSG and enhancing patient safety indicators.

References

Burgener, A. M. (2020). Enhancing communication to improve patient safety and to increase patient satisfaction. The Health Care Manager, 39(3), 128-132.

Foronda, C., MacWilliams, B., & McArthur, E. (2016). Interprofessional communication in healthcare: An integrative review. Nurse Education in Practice, 19, 36-40.

Gleason, K. T., Davidson, P. M., Tanner, E. K., Baptiste, D., Rushton, C., Day, J.,… & Newman-Toker, D. E. (2017). Defining the critical role of nurses in diagnostic error prevention: A conceptual framework and a call to action. Diagnosis, 4(4), 201-210.

Gluyas, H. (2015). Effective communication and teamwork promote patient safety. Nursing Standard (2014+), 29(49), 50-56.

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National Patient Safety Goals in an Institution

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