Assignment: Joint Commission Standard

On Week 4, I attended a Quality Council meeting with my preceptor in the morning, thereafter we attended a Practice Council meeting. In the afternoon we attended a policy protocol guidelines meeting as well as a meeting to discuss all the problems that were brought up by the mock Joint Commission survey arrival next year (2019).

On Week 5, my preceptor and I attended several meetings throughout the day. Some of the highlight of these meetings were to discuss the negative findings of the Joint Commission recent visit to Mercy Medical Center for the end of the year 2018. One major finding by the Joint Commission was the fact that nurses are not correlating the patient’s diagnosis or primary diagnosis to the patient individualized care plan. Below is the Joint Commission Standard for Documenting on patient care plans:

BACKGROUND

1. Joint Commission Standard

1. RC.02.01.01

1. The medical record contains the following clinical information:

– The reason(s) for admission for care, treatment, and services

– The patient’s initial diagnosis, diagnostic impression(s), or condition(s)

– Any findings of assessments and reassessments

– Any allergies to food

– Any allergies to medications

– Any conclusions or impressions drawn from the patient’s medical history

and physical examination

– Any diagnoses or conditions established during the patient’s course of

care, treatment, and services (including complications and hospital acquired

infections).

– Any consultation reports

– Any observations relevant to care, treatment, and services

– The patient’s response to care, treatment, and services

– Any emergency care, treatment, and services provided to the patient

before his or her arrival

– Any progress notes

– All orders

– Any medications ordered or prescribed

– Any medications administered, including the strength, dose, route, date

and time of administration

– Any access site for medication, administration devices used, and rate of

administration

– Any adverse drug reactions

– Treatment goals, plan of care, and revisions to the plan of care

– Results of diagnostic and therapeutic tests and procedures

– Any medications dispensed or prescribed on discharge

– Discharge diagnosis

– Discharge plan and discharge planning

The hospital plans the patient’s care based on needs identified by the patient assessment, reassessment, and results. The written plan of care is based on patient goals and time frames required to meet goals. Patient care plan is based on established goals where staff evaluate the patient progress Patient’s care

On Week 6, One major highlight of the meetings my preceptor and I attended was to discuss all important Epic electronic health record system complaint tickets that were sent out to the nursing informatics department. We discuss and troubleshoot the issues that the nurses are having on the mother-baby unit regarding the breast milk donor documentation taking too much (at least 20 minutes) before the nurses can feed the babies and it is impeding workflow for the nurses since they each have at least 3 babies to feed. The nurses end up having to create workarounds.

On Week 7, Some of the highlight of the day were about the Quality Council Meeting which is held every month. In this month meeting we B16 orthopedic floor which is rated number one in the area against Johns Hopkins Hospital (JHH) and University of Maryland Medical Center (UMMC). We also attended a nursing quality outcome meeting which discuss the hospital patient falls, pressure ulcers and CAUTI for the month of December. The professional practice model for the hospital was also updated and discussed.