Statement of problem:

I have learned, through the SMART study and my nursing classes, the importance of following proper protocols and documenting properly (Key insight 3). When I enter the hospital, after graduating with my nursing degree, I will be prepared to apply these skills sets to the work site. A hospital must go through an annual accreditation via Joint Commission (JCAHO) to verify they are following protocols. Accreditation is used to assure the quality of health and patient safety. My goal, as the charge nurse, is to prepare my team on the ortho/spine floor for an upcoming JCAHO visit.

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Goal:

In a hospital it is imperative that you are always prepared for a JCAHO visit. Hospital accreditation is a systematic assessment of a hospital’s operations, policies and procedures against acceptable standards and the certification is the conformation of this (Brubakk et. al. 2015).  Joint commission conducts a site visit and our policies, and our subsequent actions are not adhering protocol standards, the hospital will lose its accreditation. This certification demonstrates the conformation that a hospital is adhering to these standards. Each team member is responsible for knowing what JCAHO requires of them. For we are all a part of one team (Key insight 2), the hospital, and it is our job to maintain its accreditation.   Accreditation is not only important for the hospital and staff, but also the patients and funding for the hospital. For the patients it ensures they are receiving quality healthcare. As for funding, if the hospital is not accredited they will lose federal funding, such as Medicaid and Medicare. This could also affect patient’s ability to pay for health care.

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General solution:

Before I begin I will plan out the process and meet with other staff members of the hospital to gain their input. Then I will run through my own simulation of an unannounced site visit. This will provide me with a baseline of my team members knowledge so that I know what we need to improve upon, whether it is knowledge, attitude or skill sets. Then I will hold a mandatory floor meeting in which I will explain my results, based on the JCAHO protocols. It is important for us to reflect upon our skills sets, so that we know where we need to make improvements. I will delegate to each rank what they need to do to improve our floor. To assess if the improvements have been made, I will conduct another unannounced site.

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Implementation:

1. Plan unannounced site visit and gain accordance from staff that will be presenting at the meeting. 

2. Assess what the Ortho/spine floors weaknesses through unannounced site visit simulation.

3. Have a meeting with all the floors staff to review the results of the simulation. Different offices, like security, will present to effectively explain proper procedures to the staff.

4. Reflect on knowledge gained and apply to the floor.

 

Evaluation:

To evaluate the effectiveness of the meeting I will have each staff member complete a survey I have created. I will also go through another practice JCAHO visit and score my floor according to their standards. If my fellow staff members still feel unprepared for the visit, I will serve them (key insight 1) in any way that they may need to ensure that they are prepared. The true evaluation is not only that the floor passes its accreditation but that these protocols become a habit. These protocols may seem burdensome, but it assures that we are providing our patients quality health care.

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Reflection:

• Key insight 1- Finding myself through serving others

  • As the charge nurse of the ortho/spine floor it will be my job to ensure that my fellow staff members feel that they are prepared for a JCAHO visit. For me to serve them effective, it is necessary for me to listen to my fellow team members concern. I will also serve as being a part of the accreditation processes, this will require me to be knowledgeable as well.

• Key Insight 2- A team for one

  • For the floor to successfully pass its accreditation every member of the floor must work together. It is each staff members responsibility to have up to date knowledge of all protocols and to follow them.

• Key Insight 3- Reducing risk through documentation

  • Part of proper protocols is documenting information properly. This ensures that the patients are being taken care of and rounded on in a timely manner.  If you do not document it, you did not do it.

 

 

 

 

 

 

 

References

Brubakk, K., Vist, G., Bukholm, G., Barach, P., and Tjomsland, O. (2015) A systematic review of hospital accreditation: the challenges of measuring complex intervention effects. BMC Health Services Research 15(280) https://doi.org/10.1186/s12913-015-0933-x.