Task 1: Assessment Code: Nightingale Community Hospital

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AFT Task 1: Accreditation Audit Assessment Code: AFT2 Kyle Cluff 000505604 09/29/2015 Nelda Turner A Executive Summary Nightingale Community Hospital is a healthcare organization that prides itself on how it treats you personally. In order to help Nightingale continue the extraordinary care it provides, we partner with the Joint Commission to help mitigate breakdowns and failures, with the hopes to continuously improve the care we provide to our patients. I firmly believe that lessons learned from the past help to build future improvements. This year’s National Patient Safety Goal Data has given me a chance to analyze and focus on improvements to the Communication Management, especially under the universal protocol “Time Out.” The Time Out sections is a hospital wide procedure that is mandated under the Joint Commission standard UP.01.03.01 which says, “The purpose of the time-out is to conduct a final assessment that the correct patient, site, and procedure are identified. This requirement focuses on those minimum features of the time-out. Some believe that it is important to conduct the time-out before anesthesia for several reasons, including involvement of the patient. A hospital may conduct the time-out before anesthesia or may add another time-out at that time.…show more content…
“Hospitals should identify the timing and location of the preprocedure verification” (The Joint Commission, 2015). We have decided that the Time Out will occur immediately prior to beginning the procedure while the entire procedural team is present. The procedure will not begin until a thorough Time Out evaluation has been done. This will include using the patients chart as a reference for clarification on all variables. If there are any discrepancies between any information that do not correlate with the patients chart, the ordered procedure, or members of the team, all actions will be halted immediately and will not continue until verifications can be made on the item in

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