Sentinel Event Case Study
A1. Sentinel Event:
Nightingale Community Hospital, a not-for-profit hospital, prides itself as a leader in high quality health services and envisions itself as the hospital of choice for patients, employees, physicians, volunteers, and the community. In order to achieve its mission of creating a healing environment with a passionate commitment to healthcare excellence, Nightingale Community Hospital takes the safety and well-being of all its patients seriously. The hospital board and senior management analyze and process all sentinel events in order to prevent them from recurring. On September 14th at 12:30PM, a sentinel event, an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, occurred …show more content…
involving a child abduction. These sentinel events highlight the need for immediate investigation and response (E-dition, n.d.).
The hospital discharged Tina, a 3 year-old pediatric ambulatory surgical patient, to her non-custodial father when staff could not locate her mother, who was running an errand. Upon review of the occurrence, the following sequence of events took place:
1. During registration, the mother did not offer custodial information to the registrar. The registrar did not request any custodial information because it is not part of the standard registration process.
2. During the pre-op procedures, the pre-op nurse informed the mother that the surgical procedure would take approximately 45 minutes. Afterwards, Tina would go to the recovery room for at least one hour. The total expected time was 1 ¾ hours. The mother informed the pre-op nurse that she needed run an errand for her seven year-old son once the patient went to the operating room. The mother gave the pre-op nurse her cell phone number with instructions to call when the surgery concluded. The pre-op nurse documented the mother’s contact information on the nurse’s notebook rather than documenting in the patient’s medical record.
3. Tina’s surgery went well and finished approximately 15 minutes early. The patient moved subsequently to the recovery area. The recovery room nurse took report from the OR nurse. He then paged and called out to the waiting room, but Tina’s mother did not response. Upon completion of the hour-long recovery time, Tina moved the ambulatory surgical unit recovery room to wait for discharge. The recovery room nurse reported to the discharge nurse that Tina’s mother was not present in the waiting room.
4. The non-custodial father arrived at the hospital. The security officer informed the discharge nurse that the patient’s father was at the main reception area. The discharge nurse brought the father back to the patient. Tina appeared comforted by her father and addressed him as “Daddy”. After 30 minutes, the mother still had not returned. Patient became more anxious and wanted to go home. The father offered to take Tina home. The discharge nurse discharged the patient to her father after reviewing the discharge care instructions with him.
5. The mother was gone for a total of 2 ½ hours. Upon her return, she very upset that Tina was discharged to her father. Security interviewed the mother. The mother stated she and Tina’s father were divorced, and she had sole custody of the children. Hospital security initiated a “Code Pink” (hospital-wide child abduction alert) and notified local law enforcement.
6. Within 30 minutes of the mother’s arrival to the hospital, local law enforcement located Tina with her father at his home, where Tina and her father waited for her mother’s arrival. Law enforcement did not file charges against the father.
A2. Personnel:
Personnel: Role:
Registrar Entered demographic and insurance information into the patient’s electronic medical record, presented the condition of admission and treatment form to patient, parent, or guardian, and request and copied patient’s insurance card.
Pre-op Nurse Complete consent to treat forms, complete the pre-op nursing assessment, prepare the patient for surgery (e.g. change into gown, place IV, administer patient’s pre-op medications), and provide education to parent/guardian/family regarding the surgery wait times and procedures for reuniting with the patient post surgery. Chart nursing notes. Give nursing report to OR nurse during patient hand-off.
OR Nurse Take nursing report from pre-op nurse.
Complete time-out procedure prior to surgery. Assist the surgeon during surgery while maintaining a sterile field. Chart nursing notes. Give nursing report to recovery nurse during patient hand-off.
Recovery Nurse Take nursing report from OR nurse. Provide post-anesthesia care to the patient. Chart nursing notes. Locate patient’s parents/guardian in waiting room. Reunite parents/guardian/family with patient. Give nursing report to discharge nurse during patient hand-off.
Discharge Nurse Take nursing report from recovery nurse. Give discharge care instructions to patient/parents/guardian/family as appropriate. Discharge minor patient to parents/guardian. Discharge adult patients to family/caregivers. Chart nursing notes.
Surgeon Coordinate, communicate, and schedule patient care from his practice with the hospital ambulatory surgery unit. Perform surgical procedures in accordance with regulations.
Security Responsible for the security and safety of staff, visitors, patients, families, and volunteers of the hospital. Patrol the hospital grounds and areas for suspicious activity and persons. Notify and assist with the local law enforcement as needed for criminal offenses. Develop, review, modify, and implement hospital policies and procedures related to the safety and security of hospital …show more content…
personnel.
Chief Nursing Officer Responsible for the clinical and technical expertise of all nurses. Develop, review, modify, and implement hospital policies and procedures related to the nursing care for all patients. The CNO is responsible for reviewing all sentinel events related to nursing care and assisting with the development and implementation of a corrective action plan.
A3. Personnel Issues: Fortunately, this event with Tina ended well. However, this sentinel event highlighted barriers that negatively affected patient’s safety. It appears that nursing staff is not communicating information in a consistent manner and documenting relevant information in the electronic medical record. More concerning than the lack of comprehensible standards for documenting in the patient’s electronic medical record; clear expectation of staff responsibilities; and, lack of training to adequately handle situations when staff is not able to locate a parent of a pediatric patient is the culture of the staff disengagement. All employees had opportunities to identify problems and ask for clarification that influence patient safety and clinical outcomes prior to the sentinel event. They did not. Many did not appear willing and eager to participate in the development and implementation of solutions in order to create the safest environment for patients. During the interview process, one of the nurse stated that she did not know the standard process when a parent is not located in time to discharge a pediatric patient. However, it was not part of her standardized work to ask for assistance when she is uncertain. Therefore, she also did not ask for direction or clarification from her supervisor or fellow nurses. One staff member stated that she was too busy to participate in helping problem solve the sentinel event. Many times during the interviews, staff members expressed that they thought the responsibility to collect or report information regarding custodial rights belonged to someone else. Although it is true the registrar performed her job duties, it is concerning that she did not acknowledge the intake process needed updating to protect the safety of pediatric patients. In addition, one of the nurses stated that he does not want to implement changes to the patient hand-off procedure because it will add additional time. It is important to adjust processes and standards continuously in order to prevent this type of situation from occurring again. This requires hospital staff to be highly engaged. “Engaged employees are psychologically committed to their work, go above and beyond their basic job expectations, and want to play a key role in fulfilling the mission of their organizations” (Blizzard, 2004).
A3a. Improve Interactions:
This sentinel event highlighted the need for timely and accurate communication and interactions among clerical, clinical, medical, administrative, and support staff. In order to make these changes, staff must be clear on the expectation that all staff members are responsible for patient safety. They also have a duty to identify problems and a responsibility to develop and implement solutions. The hospital leadership must make a commitment to provide training and leadership opportunities to all employees.
In order to communicate and interact effectively and efficiently, all parties must have the same communication expectation and language. A formal training course on interpersonal communication either created by the hospital education department or contracted through an outside agency must include the following:
• Identify behavioral expectations for all patient related interactions
• Emphasis that it is everyone’s responsibility to communicate in event of patient safety.
• Develop and implement standards for all documentation to occur in the electronic medical record.
• Develop and implement formal hand-off procedures that are consistent throughout all departments.
• Encourage and value collaboration among staff members to problem solve difficult or unfamiliar situations.
• Include a mechanism to bring problems and solutions to the attention of leadership in a timely manner. The table below outlines the proposal for communication improvement rollout to all staff.
Personnel: Training Performance Measurements Due Date:
All hospital employees to include physicians with hospital privileges. The hospital will provide formal training course on interpersonal communication. 100% of the senior leader will complete training per audit of personnel records.
100% of the middle-level managers and front-line supervisors will complete training per audit of personnel records.
100% of the nursing staff, physicians, and clinical staff will complete training per audit of personnel records.
100% of the support, clerical, and technical staff will complete training per audit of personnel records. • 1/31/14
• 3/31/14
• 5/31/14
• 9/30/14
A4. Quality Improvement: Identifying the root cause, or “the source of an event, failure or defect”, is important to correct the real cause of the sentinel event (Lean Pathways, n.d.). Using Lean problem solving principles such as “A3 Thinking”, a one-paged framework for planning and improvement, and “5 Whys Analysis”, a systemic questioning technique to search for the root causes of a problem, will identify if there is a problem, the root cause of the problem, measureable countermeasures, and implementation process to rapid change. A3 Thinking objectively identifies the following items:
1. What is currently happening or point of cause, when the problem occurred?
2. The standard or the ideal performance
3. The performance gap if there is one.
4. The gap’s impact.
5. Identify performance barriers to the root cause of the barrier using the 5 Whys Analysis.
6. Develop objective and measurable countermeasures
7. Implement countermeasures and collect data using a PDCA cycle. PDCA is quality improvement tool of Plan, Do, Check, and Adjust.
Another important Lean principle is the concept of “The Warm Heart Principle”, or being kind to the people and tough on the problem.
This is important because hospital employees are valuable resources and not easily replaced. The employees are the front-line workers that provide the service and delivery the care to the patient, or hospital’s customers. These front-line employees need to be empowered to develop and implement the countermeasures to the barriers in their workflow (Lean Pathways, n.d.). The root cause analysis using Lean problem solving principles of this sentinel event identified the following: inadequate standard for patient hand-off, inadequate adherence to the standard for clinical documentation in the electronic medical record, and inadequate system to collect custodial rights
information.
B1. Risk Management Program:
The table below outlines the risk management program for prevention of future child abduction/custodial rights violations by developing standardized work, which entails defining work content, sequence, timing, and expected outcome (Lean Pathways, n.d.).
Root Cause: Risk Reduction Strategies Measures of Effectiveness Location Responsible Parties Target Date:
Inadequate standard for hand-off of patients The nursing staff of the Ambulatory Surgery Unit will develop standard work for pediatric patient hand-off.
This team will implement the pediatric patient hand-off protocol and report all outcomes to the Ambulatory Surgery Nursing supervisor.
Using PDCA, all the Ambulatory Surgery nurses will collect data for 30-days, 60-days, and 90 days to modify the standard and incorporate the adjustments into the workflow.
After 90-days, the hospital approves this standard for pediatric patient hand-off protocol for hospital-wide use.
All departments that care for pediatric patients will implement the hand-off protocol. Majority of the staff will approve the protocol.
During staff rounding, the supervisor will observe 100% of the nurses following the protocol.
During monthly staff meetings, the supervisor will report the results and findings.
Majority of the vote will approve the protocol.
During staff rounding, the supervisors will observe 100% of the nurses following the protocol. Ambulatory Surgery Unit
Ambulatory Surgery Unit
Ambulatory Surgery Unit
Hospital standards and compliance meeting.
All pediatric department and any department that provides services to pediatric patients Ambulatory Surgery Nursing supervisor
Ambulatory Surgery Nursing supervisor and nursing staff
Ambulatory Surgery Nursing supervisor and nursing staff
Hospital standards and compliance department supervisor
Chief Nursing Officer and managers from all pediatric services to include ambulatory surgery, imaging, therapy, med-surgery floor, and ER. 12/15/13
1/31/14
2/28/14
3/31/14
4/30/14
5/15/14
5/31/14
Root Cause: Risk Reduction Strategies Measures of Effectiveness Location Responsible Parties Target Date:
Inadequate adherence to the standard for clinical documentation in the electronic medical record All clinical supervisors will review the individual responsibility and role for clinical documentation with each of their staff members and document the training.
All nursing communication, patient hand-off, patient care, case coordination, and family contact information will be entered into the electronic medical record. 100% per audit of staff personnel record.
100% per chart audit.
All clinics and departments
All clinics and departments
All Medical, Nursing, and Surgical supervisors and managers.
All Medical, Nursing, and Surgical supervisors and managers.
12/31/13
1/31/14
Root Cause: Risk Reduction Strategies Measures of Effectiveness Location Responsible Parties Target Date:
Inadequate system to collect custodial rights information The Patient Accounts and Registration staff will review the current standard work for patient registration.
They will revise the standard work to include the collection of legal custodial rights information.
The Patient Registration team will implement the revised patient registration protocol and report all outcomes to the Patient Registration supervisor.
Using PDCA, the Patient Registration team will collect data for 30-days, 60-days, and 90 days to modify the standard and incorporate the adjustments into the workflow.
After 90-days, the hospital approves the revised patient registration to include the collection of legal custodial rights information.
Hospital-wide implementation of revised patient registration protocol. Staff consensus of the current protocol.
Majority of the staff will approve the revised protocol.
During staff rounding, the supervisor will observe 100% of the registrars following the revised protocol.
During monthly staff meetings, the supervisor will report the results and findings.
Majority of the vote will approve the revision.
During staff rounding, the supervisors will observe 100% of the nurses following the protocol. Patient Accounts and Registration department
Patient Accounts and Registration department
Patient Registration sub-department
Patient Accounts and Registration department
Hospital standards and compliance meeting.
All departments complete patient registration within their own department. Patient Accounts and Registration manager,
Patient Registration supervisor, and staff
Hospital Legal department staff member, Patient Accounts and Registration manager, Patient Registration supervisor, and staff.
Patient Registration supervisor and staff
Patient Accounts and Registration manager,
Patient Registration supervisor, and staff
Hospital standards and compliance department supervisor
All Medical, Nursing, Clinical, and Surgical directors, supervisors, and managers. 12/30/13
1/15/14
1/31/14
2/28/14
3/31/14
4/30/14
5/15/14
5/31/14
B.1a. Resources:
Effective communication is critical for Nightingale Community Hospital in order to ensure the safety of the patient and the delivery quality care in a cost effective manner with the best clinical outcomes. In order to implement changes to prevent child abductions and custodial rights violations in the future, the staff needs the following resources:
Resource: Description:
Hospital Leadership The senior leadership set the culture and the expectations for the hospital system and its staff. The leadership needs to send a clear message with words and actions that patient safety is priority number one for the hospital.
Hospital Printing Department The Printing department will create visual reminders of standardized workflows and educational material.
Hospital Human Resource Department Human Resources can assist with ensuring the staff received the appropriate training, protects the employment status and rights of employees and employers. This department also provides recruiting, employee satisfaction/engagement resources, and professional development support.
Hospital Education Department The Education Department has resources to create specialized training and educational resources to ensure that all employees have the proper training. This department works in conjunction with the Printing Department to create visual educational/training posters for departments.
Hospital Human Compliance Department This department ensures that all changes to standards, policies, and procedures comply with regulations.
Hospital Legal Department This department ensures that the hospital protected from legal risk as well as providing legal guidance for leadership and staff.
Security This department is a resource for developing, reviewing, modifying, and implementing hospital policies and procedures as well as any environmental changes to ensure the safety and security of hospital personnel, patients, family members, volunteers, and visitors. References
Blizzard, R. (2004, March 09). Engagement vs. satisfaction among hospital teams. Retrieved from http://www.gallup.com/poll/10903/engagement-vs-satisfaction-among-hospital-teams.aspx
E-dition. (n.d.). Retrieved from https://e-dition.jcrinc.com/MainContent.aspx
Lean Pathways. (n.d.). Lean Glossary. Retrieved from http://leansystems.org/cart.php?page=glossary
Nightingale Community Hospital, a not-for-profit hospital, prides itself as a leader in high quality health services and envisions itself as the hospital of choice for patients, employees, physicians, volunteers, and the community. In order to achieve its mission of creating a healing environment with a passionate commitment to healthcare excellence, Nightingale Community Hospital takes the safety and well-being of all its patients seriously. The hospital board and senior management analyze and process all sentinel events in order to prevent them from recurring. On September 14th at 12:30PM, a sentinel event, an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, occurred …show more content…
involving a child abduction. These sentinel events highlight the need for immediate investigation and response (E-dition, n.d.).
The hospital discharged Tina, a 3 year-old pediatric ambulatory surgical patient, to her non-custodial father when staff could not locate her mother, who was running an errand. Upon review of the occurrence, the following sequence of events took place:
1. During registration, the mother did not offer custodial information to the registrar. The registrar did not request any custodial information because it is not part of the standard registration process.
2. During the pre-op procedures, the pre-op nurse informed the mother that the surgical procedure would take approximately 45 minutes. Afterwards, Tina would go to the recovery room for at least one hour. The total expected time was 1 ¾ hours. The mother informed the pre-op nurse that she needed run an errand for her seven year-old son once the patient went to the operating room. The mother gave the pre-op nurse her cell phone number with instructions to call when the surgery concluded. The pre-op nurse documented the mother’s contact information on the nurse’s notebook rather than documenting in the patient’s medical record.
3. Tina’s surgery went well and finished approximately 15 minutes early. The patient moved subsequently to the recovery area. The recovery room nurse took report from the OR nurse. He then paged and called out to the waiting room, but Tina’s mother did not response. Upon completion of the hour-long recovery time, Tina moved the ambulatory surgical unit recovery room to wait for discharge. The recovery room nurse reported to the discharge nurse that Tina’s mother was not present in the waiting room.
4. The non-custodial father arrived at the hospital. The security officer informed the discharge nurse that the patient’s father was at the main reception area. The discharge nurse brought the father back to the patient. Tina appeared comforted by her father and addressed him as “Daddy”. After 30 minutes, the mother still had not returned. Patient became more anxious and wanted to go home. The father offered to take Tina home. The discharge nurse discharged the patient to her father after reviewing the discharge care instructions with him.
5. The mother was gone for a total of 2 ½ hours. Upon her return, she very upset that Tina was discharged to her father. Security interviewed the mother. The mother stated she and Tina’s father were divorced, and she had sole custody of the children. Hospital security initiated a “Code Pink” (hospital-wide child abduction alert) and notified local law enforcement.
6. Within 30 minutes of the mother’s arrival to the hospital, local law enforcement located Tina with her father at his home, where Tina and her father waited for her mother’s arrival. Law enforcement did not file charges against the father.
A2. Personnel:
Personnel: Role:
Registrar Entered demographic and insurance information into the patient’s electronic medical record, presented the condition of admission and treatment form to patient, parent, or guardian, and request and copied patient’s insurance card.
Pre-op Nurse Complete consent to treat forms, complete the pre-op nursing assessment, prepare the patient for surgery (e.g. change into gown, place IV, administer patient’s pre-op medications), and provide education to parent/guardian/family regarding the surgery wait times and procedures for reuniting with the patient post surgery. Chart nursing notes. Give nursing report to OR nurse during patient hand-off.
OR Nurse Take nursing report from pre-op nurse.
Complete time-out procedure prior to surgery. Assist the surgeon during surgery while maintaining a sterile field. Chart nursing notes. Give nursing report to recovery nurse during patient hand-off.
Recovery Nurse Take nursing report from OR nurse. Provide post-anesthesia care to the patient. Chart nursing notes. Locate patient’s parents/guardian in waiting room. Reunite parents/guardian/family with patient. Give nursing report to discharge nurse during patient hand-off.
Discharge Nurse Take nursing report from recovery nurse. Give discharge care instructions to patient/parents/guardian/family as appropriate. Discharge minor patient to parents/guardian. Discharge adult patients to family/caregivers. Chart nursing notes.
Surgeon Coordinate, communicate, and schedule patient care from his practice with the hospital ambulatory surgery unit. Perform surgical procedures in accordance with regulations.
Security Responsible for the security and safety of staff, visitors, patients, families, and volunteers of the hospital. Patrol the hospital grounds and areas for suspicious activity and persons. Notify and assist with the local law enforcement as needed for criminal offenses. Develop, review, modify, and implement hospital policies and procedures related to the safety and security of hospital …show more content…
personnel.
Chief Nursing Officer Responsible for the clinical and technical expertise of all nurses. Develop, review, modify, and implement hospital policies and procedures related to the nursing care for all patients. The CNO is responsible for reviewing all sentinel events related to nursing care and assisting with the development and implementation of a corrective action plan.
A3. Personnel Issues: Fortunately, this event with Tina ended well. However, this sentinel event highlighted barriers that negatively affected patient’s safety. It appears that nursing staff is not communicating information in a consistent manner and documenting relevant information in the electronic medical record. More concerning than the lack of comprehensible standards for documenting in the patient’s electronic medical record; clear expectation of staff responsibilities; and, lack of training to adequately handle situations when staff is not able to locate a parent of a pediatric patient is the culture of the staff disengagement. All employees had opportunities to identify problems and ask for clarification that influence patient safety and clinical outcomes prior to the sentinel event. They did not. Many did not appear willing and eager to participate in the development and implementation of solutions in order to create the safest environment for patients. During the interview process, one of the nurse stated that she did not know the standard process when a parent is not located in time to discharge a pediatric patient. However, it was not part of her standardized work to ask for assistance when she is uncertain. Therefore, she also did not ask for direction or clarification from her supervisor or fellow nurses. One staff member stated that she was too busy to participate in helping problem solve the sentinel event. Many times during the interviews, staff members expressed that they thought the responsibility to collect or report information regarding custodial rights belonged to someone else. Although it is true the registrar performed her job duties, it is concerning that she did not acknowledge the intake process needed updating to protect the safety of pediatric patients. In addition, one of the nurses stated that he does not want to implement changes to the patient hand-off procedure because it will add additional time. It is important to adjust processes and standards continuously in order to prevent this type of situation from occurring again. This requires hospital staff to be highly engaged. “Engaged employees are psychologically committed to their work, go above and beyond their basic job expectations, and want to play a key role in fulfilling the mission of their organizations” (Blizzard, 2004).
A3a. Improve Interactions:
This sentinel event highlighted the need for timely and accurate communication and interactions among clerical, clinical, medical, administrative, and support staff. In order to make these changes, staff must be clear on the expectation that all staff members are responsible for patient safety. They also have a duty to identify problems and a responsibility to develop and implement solutions. The hospital leadership must make a commitment to provide training and leadership opportunities to all employees.
In order to communicate and interact effectively and efficiently, all parties must have the same communication expectation and language. A formal training course on interpersonal communication either created by the hospital education department or contracted through an outside agency must include the following:
• Identify behavioral expectations for all patient related interactions
• Emphasis that it is everyone’s responsibility to communicate in event of patient safety.
• Develop and implement standards for all documentation to occur in the electronic medical record.
• Develop and implement formal hand-off procedures that are consistent throughout all departments.
• Encourage and value collaboration among staff members to problem solve difficult or unfamiliar situations.
• Include a mechanism to bring problems and solutions to the attention of leadership in a timely manner. The table below outlines the proposal for communication improvement rollout to all staff.
Personnel: Training Performance Measurements Due Date:
All hospital employees to include physicians with hospital privileges. The hospital will provide formal training course on interpersonal communication. 100% of the senior leader will complete training per audit of personnel records.
100% of the middle-level managers and front-line supervisors will complete training per audit of personnel records.
100% of the nursing staff, physicians, and clinical staff will complete training per audit of personnel records.
100% of the support, clerical, and technical staff will complete training per audit of personnel records. • 1/31/14
• 3/31/14
• 5/31/14
• 9/30/14
A4. Quality Improvement: Identifying the root cause, or “the source of an event, failure or defect”, is important to correct the real cause of the sentinel event (Lean Pathways, n.d.). Using Lean problem solving principles such as “A3 Thinking”, a one-paged framework for planning and improvement, and “5 Whys Analysis”, a systemic questioning technique to search for the root causes of a problem, will identify if there is a problem, the root cause of the problem, measureable countermeasures, and implementation process to rapid change. A3 Thinking objectively identifies the following items:
1. What is currently happening or point of cause, when the problem occurred?
2. The standard or the ideal performance
3. The performance gap if there is one.
4. The gap’s impact.
5. Identify performance barriers to the root cause of the barrier using the 5 Whys Analysis.
6. Develop objective and measurable countermeasures
7. Implement countermeasures and collect data using a PDCA cycle. PDCA is quality improvement tool of Plan, Do, Check, and Adjust.
Another important Lean principle is the concept of “The Warm Heart Principle”, or being kind to the people and tough on the problem.
This is important because hospital employees are valuable resources and not easily replaced. The employees are the front-line workers that provide the service and delivery the care to the patient, or hospital’s customers. These front-line employees need to be empowered to develop and implement the countermeasures to the barriers in their workflow (Lean Pathways, n.d.). The root cause analysis using Lean problem solving principles of this sentinel event identified the following: inadequate standard for patient hand-off, inadequate adherence to the standard for clinical documentation in the electronic medical record, and inadequate system to collect custodial rights
information.
B1. Risk Management Program:
The table below outlines the risk management program for prevention of future child abduction/custodial rights violations by developing standardized work, which entails defining work content, sequence, timing, and expected outcome (Lean Pathways, n.d.).
Root Cause: Risk Reduction Strategies Measures of Effectiveness Location Responsible Parties Target Date:
Inadequate standard for hand-off of patients The nursing staff of the Ambulatory Surgery Unit will develop standard work for pediatric patient hand-off.
This team will implement the pediatric patient hand-off protocol and report all outcomes to the Ambulatory Surgery Nursing supervisor.
Using PDCA, all the Ambulatory Surgery nurses will collect data for 30-days, 60-days, and 90 days to modify the standard and incorporate the adjustments into the workflow.
After 90-days, the hospital approves this standard for pediatric patient hand-off protocol for hospital-wide use.
All departments that care for pediatric patients will implement the hand-off protocol. Majority of the staff will approve the protocol.
During staff rounding, the supervisor will observe 100% of the nurses following the protocol.
During monthly staff meetings, the supervisor will report the results and findings.
Majority of the vote will approve the protocol.
During staff rounding, the supervisors will observe 100% of the nurses following the protocol. Ambulatory Surgery Unit
Ambulatory Surgery Unit
Ambulatory Surgery Unit
Hospital standards and compliance meeting.
All pediatric department and any department that provides services to pediatric patients Ambulatory Surgery Nursing supervisor
Ambulatory Surgery Nursing supervisor and nursing staff
Ambulatory Surgery Nursing supervisor and nursing staff
Hospital standards and compliance department supervisor
Chief Nursing Officer and managers from all pediatric services to include ambulatory surgery, imaging, therapy, med-surgery floor, and ER. 12/15/13
1/31/14
2/28/14
3/31/14
4/30/14
5/15/14
5/31/14
Root Cause: Risk Reduction Strategies Measures of Effectiveness Location Responsible Parties Target Date:
Inadequate adherence to the standard for clinical documentation in the electronic medical record All clinical supervisors will review the individual responsibility and role for clinical documentation with each of their staff members and document the training.
All nursing communication, patient hand-off, patient care, case coordination, and family contact information will be entered into the electronic medical record. 100% per audit of staff personnel record.
100% per chart audit.
All clinics and departments
All clinics and departments
All Medical, Nursing, and Surgical supervisors and managers.
All Medical, Nursing, and Surgical supervisors and managers.
12/31/13
1/31/14
Root Cause: Risk Reduction Strategies Measures of Effectiveness Location Responsible Parties Target Date:
Inadequate system to collect custodial rights information The Patient Accounts and Registration staff will review the current standard work for patient registration.
They will revise the standard work to include the collection of legal custodial rights information.
The Patient Registration team will implement the revised patient registration protocol and report all outcomes to the Patient Registration supervisor.
Using PDCA, the Patient Registration team will collect data for 30-days, 60-days, and 90 days to modify the standard and incorporate the adjustments into the workflow.
After 90-days, the hospital approves the revised patient registration to include the collection of legal custodial rights information.
Hospital-wide implementation of revised patient registration protocol. Staff consensus of the current protocol.
Majority of the staff will approve the revised protocol.
During staff rounding, the supervisor will observe 100% of the registrars following the revised protocol.
During monthly staff meetings, the supervisor will report the results and findings.
Majority of the vote will approve the revision.
During staff rounding, the supervisors will observe 100% of the nurses following the protocol. Patient Accounts and Registration department
Patient Accounts and Registration department
Patient Registration sub-department
Patient Accounts and Registration department
Hospital standards and compliance meeting.
All departments complete patient registration within their own department. Patient Accounts and Registration manager,
Patient Registration supervisor, and staff
Hospital Legal department staff member, Patient Accounts and Registration manager, Patient Registration supervisor, and staff.
Patient Registration supervisor and staff
Patient Accounts and Registration manager,
Patient Registration supervisor, and staff
Hospital standards and compliance department supervisor
All Medical, Nursing, Clinical, and Surgical directors, supervisors, and managers. 12/30/13
1/15/14
1/31/14
2/28/14
3/31/14
4/30/14
5/15/14
5/31/14
B.1a. Resources:
Effective communication is critical for Nightingale Community Hospital in order to ensure the safety of the patient and the delivery quality care in a cost effective manner with the best clinical outcomes. In order to implement changes to prevent child abductions and custodial rights violations in the future, the staff needs the following resources:
Resource: Description:
Hospital Leadership The senior leadership set the culture and the expectations for the hospital system and its staff. The leadership needs to send a clear message with words and actions that patient safety is priority number one for the hospital.
Hospital Printing Department The Printing department will create visual reminders of standardized workflows and educational material.
Hospital Human Resource Department Human Resources can assist with ensuring the staff received the appropriate training, protects the employment status and rights of employees and employers. This department also provides recruiting, employee satisfaction/engagement resources, and professional development support.
Hospital Education Department The Education Department has resources to create specialized training and educational resources to ensure that all employees have the proper training. This department works in conjunction with the Printing Department to create visual educational/training posters for departments.
Hospital Human Compliance Department This department ensures that all changes to standards, policies, and procedures comply with regulations.
Hospital Legal Department This department ensures that the hospital protected from legal risk as well as providing legal guidance for leadership and staff.
Security This department is a resource for developing, reviewing, modifying, and implementing hospital policies and procedures as well as any environmental changes to ensure the safety and security of hospital personnel, patients, family members, volunteers, and visitors. References
Blizzard, R. (2004, March 09). Engagement vs. satisfaction among hospital teams. Retrieved from http://www.gallup.com/poll/10903/engagement-vs-satisfaction-among-hospital-teams.aspx
E-dition. (n.d.). Retrieved from https://e-dition.jcrinc.com/MainContent.aspx
Lean Pathways. (n.d.). Lean Glossary. Retrieved from http://leansystems.org/cart.php?page=glossary