Accreditation Standards Compliance
Western Governors University
The Joint Commission began using tracer methodology in 2004. This tool provides a view of the patient’s experience with care, treatment, and services. The patient’s stay is not just seen on one unit on one day, but from admission to transfer or discharge. This tool involves the frontline nurse, who is asked to answer questions regarding policies, procedures, and treatment. The tracer also gives insight into the consistency of care provided by caregivers (Phillion, 2009).
During a recent survey by The Joint Commission, a patient tracer revealed multiple issues for improvement. The issue examined in this paper is failure to use “read back.” A surveyor noted that the nurse did not use the “read back” process when describing receipt of a critical lab value. The need to read back is covered in The Joint Commission Accreditation Requirement “Provision of Care, Treatment, and Services.” This requirement is listed as PC.02.01.03 (20), which reads, “Before taking action on a verbal order or verbal report of a critical test result, staff uses a record and ‘read back’ process to verify the information.” (The Joint Commission, 2015) . The following is the corrective action plan to address this issue.
Evidence of Standards Compliance
The Chief Nurse Executive of Nightingale Community Hospital is ultimately responsible for the corrective action plan and ongoing compliance.
The Nightingale Community Hospital policy regarding “Verbal Order/Verbal Report – Read Back and Verify” was reviewed on June 1, 2015, by the Chief Nurse Executive, Director of Inpatient and Emergency Services Nursing, Chief Medical Officer and Performance Improvement. The committee agreed that the policy was compliant with The Joint Committee Accreditation Requirement, but education was needed. The Chief Medical Officer discussed the policy with all physicians at their...