Up to present times, organization willingness to adopt change within the healthcare setting is a significant factor when it comes to the fortunate effectuation of the new policies, practices, and programs. According to Ajami, Ketabi, Isfahani, and Heidani (2011) an organization readiness to manage the information, protocols, procedures, EHR vendor relationship management, and the multidisciplinary staff is required in today’s healthcare to improve the care provided to patients. In this case, tracer patient’s information will be essential in the sense that there will be increased accessed to patient’s information that will be used to assess the organization’s compliance with Joint Commissions Standards. In effect, high-quality safety and healthcare services are provided efficiently to the patients, which improves their health and well-being. This paper, therefore, provides a review of outstanding patient care issue presented in the tracer patient’s information from Nightingale Community Hospital. Additionally, the article offers a comprehensive correction action plan that the organization requires to improve the patient care.
Although making patient health information available is essential, various healthcare setting faced with complex problems in implementing health information system (Ajami, Sima, et al., 2011). For instance, in the Accreditation Audit of the tracer patient information at Nightingale Health Community, there are significant loopholes and outstanding and outstanding patient care issue that has been made evident by the racer patient information. Based on the notion that breakdown of the patient’s assessment information impacts their safety and the quality of care, treatment, and services, trace methodology should apply to information flow in all types of hospitals to ensure satisfactory performance. For example, in the tracer worksheet of the case provided, it is quite clear that the first patient’s admission assessment was carried out; however, it was not done within the 24 hours of admission (Accreditation Audit Case Study).
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On the other hand, another significant general issue that tracer patient worksheet identified in the case was lack of proper documentation. For example, actions of the functional assessment of those problems that triggered PT, OT, OR SLP referral was based on the admission assessment, but there was no record or documentation of the action. Similarly, there was no documentation on the advance directives as the nurse reported that the patient did not bring it with her. Additionally, the trace information reposted that the patient had a care plan action; however, this document was never updated since the surgery. Finally, in the pain assessment action, the tracer indicated that there was medication administered for the pain and was supposed to check on effect on1 hour, however, the documentation was done past one for the last four times.
Conversely, another critical issue that was presented in the racer patient information was related to an environment of care. Being one of the significant factors when it comes to the quality and safety care, it was indicating in the tracer that that oxygen tanks were found on the flow and was not secured. Moreover, air vents were dusty both in the utility and patient room. Separately, another devastating issue that the tracer methodology identified was based on the policy of the range of order. In the report, it was clear that the Nurse was not able to comprehensively explain range order policy. In response to what she would give if the range were 25mg-100mg, she answered 100mg (Accreditation Audit Case Study).
Corrective Action Plan
To achieve high-quality care, tracer patient information should be understood and covered in all aspects to measure and manage patients efficiently flow. Besides, the implementation of the health information system will indicate the readiness assessment that understands the importance of the usefulness of the of the patient documentation in electronic health record (Ajami, Sima, et al., 2011). Therefore, a comprehensive action plan should be flowed to correct the outstanding issues that are evident in the tracer patient provided in the case study.
To start with, in line with the Joint Commission Standards, healthcare providers in the accredited healthcare organization, in this case, Nightingale Health Community, should daily work to engage the patients and multidisciplinary team throughout the healthcare system. In this case, patient documentation should frequently be updated with proper assessment both at the admission and re-assessments level. This should also be accompanied by appropriate evaluations to prevent or reducing harm to the patient (CAMH, 2016). This should be done grounded on the basis that patient safety should emerge as a primary aim of quality.
Effective prevention of patient's health record errors and adverse risks to the patient at Nightingale Health Community. Similarly, patient's medical records should be operative to increase clear assessment and re-assessment. Besides, an environment of care should clean with oxygen tanks stored in secure stands.
Another action plan that should correct the outstanding issue based on the pain assessment should involve providing the accredited health organization with advancing skills, knowledge, and competence of the staff and patient through recommendations that will improve the quality and safety processes (CAMH, 2016). For example, patient or family supportive individual should provide advance directives which will provide a consent of their will on the actions to be taken for their health if they are no longer able to make decisions for themselves.
On the other hand, the interdisciplinary team should be provided with proper training that encompasses proactive quality and safety procedures and protocols that increases accountability, knowledge, and collective mindfulness when delivering services. Besides, the hospital should have an active collaborative process that ensures appropriate care and treatment to the patient needs with an effective care plan.
References
Accreditation Audit Case Study (2010). Surgical Patient Tracer Worksheet: Nightingale Community Hospital.
Ajami, S., Ketabi, S., Isfahani, S. S., & Heidari, A. (2011). Readiness Assessment of Electronic Health Records Implementation. Acta Informatica Medica , 19 (4), 224–227. http://doi.org/10.5455/aim.2011.19.224-227
CAMH. (2016). Patient Safety System. Comprehensive Accreditation Manual for Hospitals. Available from https://www.jointcommission.org/assets/1/18/PSC_for_Web.pdf
