Continuously improving the quality of care provided to individuals is essential for meeting accreditation requirements and preventing malpractice. Cases of individual patients are an excellent source of information for care providers that could help to evaluate gaps in the quality of care delivered to patients and design improvements to address them. Furthermore, tracer cases can assist in assessing compliance with accreditation requirements, thus preparing institutions to be accredited by the Joint Commission. In the present case, the patient is a 67-year-old female who had a laparoscopic hysterectomy. Seven days ago, she was readmitted due to concerns regarding a possible postoperative infection. In two days, she received surgery to treat the abscess on the previous surgery site and is currently receiving antibiotic therapy. By reviewing comprehensive information about the case, the Director of Accreditation will identify the required improvements and suggest a plan for their implementation. The conclusions made as part of the evaluations will thus help the institution to meet relevant accreditation standards.
Evaluation
According to the case scenario, the patient was admitted with a postoperative wound infection and received surgery for drainage. She was prescribed a long course of antibiotics to help cope with the infection and should be discharged in a couple of days to obtain further health care at home. The patient did not receive a history and physical exam within 24 hours of admission. In fact, it has the exam delayed by over 72 hours, indicating a critical breach of care standards. The nurse was able to verbalize the medication reconciliation process and had evidence of reconciliation on admission and after surgery. A functional assessment of the patient was also performed, but there was no documentation relating to it. However, the nutritional assessment was documented, and the nurse found indications for social work referral. She also stated that the patient had an advance directive, but the family failed to bring it.
A skin assessment was performed on the patient on admission, indicating a risk of skin breakdown, and the patient was put on a specialty bed. The patient’s fall risk was also highlighted on the handoff form, necessitating slip-proof socks and night light. The initial nursing plan of care was documented, but no updates to it have been made following the surgeries. The patient had no barriers to learning, and patient education was administered as planned. The care providers involved in the case communicated with one another using process notes and one-on-one conversations. The pain was assessed at regular intervals using a numerical pain scale, and pain medications were offered as required. The environment of care showed some concerns since oxygen tanks were not secured, and air vents were dusty. The nurse claimed to use the read-back process when taking verbal orders over the phone but did not apply it when describing the patient’s critical values. They were also unable to explain the range order policy and admitted that she would give a maximum doze if the range was 25 to 100 mg. A color-coded armband was used to identify the patient’s DNR status, blood consent was signed properly, and the blood was double-checked with the RN. The nurse also reported doing rounds when possible and using the SBAR format in communication. Still, the process of handoff was disjointed, with inconsistent use of formal handoff documentation.
Overall, the case offers evidence of several critical issues that threaten the institution’s compliance with the requirements of the Joint Commission. However, the most critical breaches were related to documentation and patient assessments. The fact that the patient did not receive a history and physical within 24 hours of admission directly opposes the standard PC.01.02.03. According to the Joint Commission (2019), this standard necessitates hospitals to define time frames for continuous patient assessment during care provision and adheres to these time frames. In the present case, the time frame required for the hospital (24 hours) was not followed. Instead, the patient only received a history and physical after more than 72 hours, which is three times the defined limit. This indicates a serious breach that has threatened the patient’s health outcomes and life, particularly considering the fact that she was scheduled for surgery 48 hours after admission. For patients undergoing surgery, medical history and physical examination should be administered before the surgery. Therefore, the case shows a breach of the assessment and reassessment standard defined by the Joint Commission.
An initial patient assessment, including history and physical, is essential for understanding the patient’s condition, evaluating their risks, and defining the course of treatment (Renom-Guiteras, Uhrenfeldt, Meyer, & Mann, 2014; Yamakava et al., 2011). Furthermore, an assessment must be performed prior to the surgery to define if it is safe for the patient or if there are any considerations that anesthesiologists and surgeons have to take into account during the operation (Zambouri, 2007). By not assessing the patient’s medical history and performing a physical exam within the first 24 hours of admission, the nurses have put the patient at risk of further complications associated with her condition. Moreover, it is unclear whether all of the risk factors of the patient were identified without the data gathered from history and physical. Reports suggest that the Joint Commission’s standard regarding patient assessments and reassessments is one of the most frequently breached by institutions. For instance, Patient Safety Monitor (2011) shows that over 30% of hospitals receive a requirement for improvement in standard PC.01.02.03. This suggests that the issue is important to patient safety in contemporary healthcare and that Nightingale Community Hospital should use the tracer patient case as an opportunity to design, plan, and implement the necessary improvements.
Plan
In order to address the situation and prevent similar occurrences in the future, it is critical for the hospital to undertake several steps. First of all, interviews with the nurses responsible for the patient’s admission and care should be performed to clarify the problems that delayed the history and physical assessment. This will help to understand the root cause of the issues evident in the case and design strategies for targeting them. Next, the hospital should also review its current policies to determine if there are any gaps that could mislead the staff to think that initial assessments can be delayed. If so, these gaps should be addressed, and an updated policy enforcing strict initial assessment time frames should be published. Moreover, the personnel should be made aware of the correct admission process to ensure that they understand the requirements and can comply with them in their work.
The hospital would also benefit from introducing new control mechanisms that would help to track admission assessment time frames at the unit level. For example, collecting information on how many hours have passed between each patient’s admission and the assessment of their history and physical condition would give the Director a clearer picture of the situation, thus showing the trends in the whole institution. If some units perform worse than others, it might be necessary to add more control mechanisms or perform further analysis to understand the reasons for failing the requirements. As part of this process, staffing levels could be taken into account since nurses might forget to perform some duties as required if their workload is too high. On the whole, the proposed plan involves a more in-depth evaluation of the case, the introduction of new controls, and an analysis of the situation in units that do not meet the standard.
Conclusion
The case offered for a review presents several vital problems that mark the institution’s lack of compliance with the standards defined by the Joint Commission. This can have a negative effect on the whole institution by inhibiting the accreditation process, as well as on patients, by hurting their outcomes and satisfaction with care. One of the most prominent standards that were not met in the case was the standard for patient assessments and reassessments. Scholars confirm the necessity of evaluating patients’ history and physical condition within a day of their admission, as well as before the surgery. Failure to comply with this standard limited the quality of care rendered to the patient in this case and identified the need for improvements. The proposed plan could help the hospital to avoid similar problems in the future by addressing the core reasons for delayed admission assessments.
References
The Joint Commission. (2019). Joint Commission standards summary form. Web.
Patient Safety Monitor. (2011). Joint Commission: PC.01.02.03 one of top compliance issues. Web.
Renom-Guiteras, A., Uhrenfeldt, L., Meyer, G., & Mann, E. (2014). Assessment tools for determining appropriateness of admission to acute care of persons transferred from long-term care facilities: a systematic review. BMC Geriatrics, 14(1), 80.
Yamakawa, K., Tasaki, O., Fukuyama, M., Kitayama, J., Matsuda, H., Nakamori, Y.,… & Shimazu, T. (2011). Assessment of risk factors related to healthcare-associated methicillin-resistant Staphylococcus aureus infection at patient admission to an intensive care unit in Japan. BMC Infectious Diseases, 11(1), 1-7.
Zambouri, A. (2007). Preoperative evaluation and preparation for anesthesia and surgery. Hippokratia, 11(1), 13-21.