705.3.4 : Patient Care Improvement
The graduate interprets quality assessments and prioritizes patient care improvement needs.
INTRODUCTION
In this task, you will use a tracer methodology to track a patient’s care in order to evaluate the healthcare organization’s systems of providing care and services for a readiness audit. This methodology also makes it possible to assess the healthcare organization’s compliance with Joint Commission standards. This is part of the organization’s compliance with delivering safe, quality healthcare.

You will examine data for a patient that is found in the attached “Accreditation Audit Case Study – Task 3 Artifacts” and find any trends, patterns, and problems. Once these have been identified, you can remediate the concerns.
REQUIREMENTS
Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. The originality report that is provided when you submit your task can be used as a guide.
You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.
A.  Review the tracer patient information from the attached Accreditation Audit Case Study – Task 3 Artifacts and do the following:
1.  Discuss an outstanding patient care issue for the organization made evident by the tracer patient.
2.  Develop a corrective action plan to address the patient care improvement needs for the organization using a keyword search in the Joint Commission electronic manual.
Surgical Patient
Surgical Patient Tracer Worksheet
Nightingale Community Hospital – in Year 2 of Audit Cycle
MR#__453355______________________
Admission/Service Start Date:___________
Language/Culture:_English_____________
Tracer Surveyor(s):
Sequence of Care/Services
Date
Admitting/Presenting Dx/Condition:
1._Surgical Nursing Unit__________
2. _Radiology_______________________
3. _OR_____________________________
4. _PACU__________________________
Admitted with post-op wound
infection
Went to surgery for drainage
Long term antibiotics
Supportive spouse
Plan home health at discharge
Current Location _Surgical Nsg Unit ___
Questions / Actions
Ask the staff member to give you a report
on the patient like he/she may give to an
oncoming shift.
Notes/Deficiencies Identified
Tracer Tips
Does the staff member know the course of
care?
Show me the patient’s admission
assessment (or initial nursing assessment).
When is the assessment done?
By whom?
Can an LPN do an admission assessment?
History and physical not done within
24 hours of admission (> 72 hours)
Review admission history
Ask nurse about any gaps or blank areas
Should be completed by end of shift when pt
admitted
Ask about med reconciliation process
How is care plan generated?
Describe the medication reconciliation
process.
Primary nurse able to verbalize med
reconciliation process.
Review of chart had evidence of med
reconciliation on admission and after
surgery
Where is your functional assessment?
OR
What precipitates PT, OT, or SLP referral?
Function assessment triggered based
on admission assessment but no
documentation found
Nutritional assessment documented
Home med list is obtained and verified at
time of admission
Med recon done when patient transfers
location (OR to floor, floor to floor, ICU to
floor, etc)
Med Recon is done at discharge—any
discrepancies and nurse can hold up
discharge
Have staff show f/u if a referral was
triggered.
Where is your nutritional assessment?
Have staff show dietitian’s f/u if a referral
was triggered.
What would precipitate a social work
referral?
Nurse verbalized indications for
social work referral
Have staff show social worker’s f/u if a
referral was triggered
Does this patient have advance
directives?
Where is it documented?
Is a copy of the document in the medical
record?
Nurse said patient has an advance
directive but did not bring it with her.
Family was reminded a copy was
needed but failed to bring in.
If patient does not have Advance Directive,
was information provided?
What are the patient’s allergies?
No allergies
Note allergies on all documents where they
are documented (ie, H&P, ED, MAR) and
whether all sources agree.
Does this patient have any cultural/
spiritual needs?
Priority Focus Areas (PFA) Addressed:
? Assessment & Care/Services
?Communication
Credentialed/Privileged Practitioners
Equipment Use
? Infection Control
Information Mgmt
? Medication Mgmt
Organization Structure
Orientation & Training
? Rights & Ethics
Physical Environment
? Quality Improvement
? Patient Safety
Staffing
Coach staff to avoid responses with
“usually”, “sometimes,” and other
descriptions that could indicate that
the practice is not consistent.
Questions / Actions
Is this patient at risk for skin breakdown
problems?
Where is it documented?
What breakdown prevention measures are
taken?
Notes/Deficiencies Identified
Is this patient at risk for falls?
Where is it documented?
How is the risk for falls communicated shift
to shift? Dept to dept?
What precautions have been implemented
for this patient?
Yes. Documented in the nursing
admission assessment. Fall risk is
included in handoff form.
Precautions: slip proof socks, night
light
Does this patient have a plan of care?
How are care plans updated or changed?
How do all disciplines come together for a
plan of care?
Initial nursing plan of care
documented but not updated since
surgery.
Interdisciplinary Rounds (IDR) or Caring
Rounds
Are IDR documented?
Are care plans reviewed daily? And updated?
What type of patient education has the
patient received and where is it
documented?
Where are the patient’s educational needs
assessed?
Does this patient have any barriers to
learning?
How does this patient learn best?
How do you know if patient understands the
education provided?
No barriers to learning identified.
Patient education has been on-going
since admission.
With husband’s assistance, patient
has demonstrated central line
dressing change.
On inpatient units, nurse should go to
Meditech and pull up documentation
Also check discharge instruction sheet.
Educational assessment, preferences and
learning needs should be in Meditech
What is the discharge plan?
Where is the discharge plan documented?
Home with home health
How do you communicate patient info
among disciplines?
Interdisciplinary progress notes and
1:1
What is your policy for pain assessment?
Show me the pain documentation in this
chart.
Do you use pain scales?
How would you assess for pain in a nonverbal patient (infant, child, adult)?
How do you document effectiveness of pain
treatment?
What is the time frame for reassessment?
Pain assessed at least every 4 hours.
Uses 0-10 pain scale.
When pain med given, supposed to
check on effect within 1 hour but
documentation was > 1 hour the last
4 times.
Documentation found should correspond
with pain assessment policy.
Look for pain assessments with reports of
moderate or severe pain (4-5 or above) and
ask if treatment was given. If no treatment,
why not?
If treatment given, how does nurse know if
it was effective?
Find pain med administration on MAR and
ask nurse to show the pain reassessment.
Oxygen tanks found on floor and not
secured
Air vents dusty in clean utility room
and patient room
Nurse described process using “repeat
back”—reviewed proper process of
writing down the MDs order and then
repeating back to MD
Did not use “read back” process when
describing receipt of critical values.
Oxygen tanks need to be stored in secure
stands
Code carts require checks every shift
Nurse verbalized “Name and Medical
Record #”
Name and MR#
How do you educate patients about pain?
Environment of Care—for example:
Storage of oxygen tanks
Code Carts
Overall cleanliness
Hallway clutter
What is the process for taking a telephone
or verbal order?
Do you ever take verbal orders face-toface?
Do you receive calls with critical values or
test results?
What do you do when you receive a call
about critical values?
How do you document critical values?
What are the 2 identifiers that you use to
identify patients prior to administering
medications and blood?
Tracer Tips
Yes due to infection and poor
nutritional intake. Skin assessment
done on admission. Patient on
specialty bed
Looking for statement regarding readback. Staff should not say repeat back.
Looking for nurse to say that he/she would
ask the MD to write the order if face-to-face.
Looking for statement regarding read back.
Document in MD Notification screen
Questions / Actions
What do you do if a physician writes an
order with one of the unacceptable
abbreviations?
Notes/Deficiencies Identified
Examine physician orders.
Incomplete orders—call physician and
request missing part of order.
Follow up on any order that is not complete
or would require judgment (e.g., titrate to
BP> 60, administer slowly, taper, etc.)
Ask staff what action would be taken for
illegible or incomplete order.
What is your policy for range orders?
Nurse not able to explain range order
policy. When asked what she would
give if range was 25mg-100mg, she
answered 100mg.
Patient would wear a purple arm
band.
For any range order found, ask staff
member how he/she would implement the
order.
Did this patient receive blood?
What is your process for blood
administration?
What do you do if patient has a reaction to
transfusion? (ie spikes temperature)
Yes. Blood consent signed and on
chart. Blood double checked with
another RN.
Examine blood administration documents for
completeness.
Is there a standard communication
method that you use when you are giving
report or calling a physician about a patient?
Try to do rounds at bedside when
possible. Uses SBAR when calling
MD.
Disjointed hand-off process,
inconsistent use of handoff form
Response should refer to SBAR
How is DNR status communicated and
documented?
Describe hand off process (ie, from PACU
to floor or ICU to floor)
What are PI projects in progress that
pertain to your area?
Tracer Tips
Call him and clarify order. Rewrite
verbal order without abbreviation
Response should refer to handoff form.
Fall prevention
SDS /
Questions / Actions
What is your process for informed
consent?
Notes/Deficiencies Identified
Who marks side/site?
How is the site marked?
When is the site marked?
surgeon marks the site with his
initials, usually in SDS pre-op area
but always before taken to OR
Anesthesia marks the site
Regional Blocks– Who marks the site?
Do you do a time out?
Do you do time outs?
When is the time out done?
Who is present for time out?
Give me an example when you would use
override (Pyxis).
Signed prior to sedation given. No
abbreviations allowed.
Yes, when we do regional blocks—and
it is done immediately prior to
sticking patient. The nurse,
anesthesiologist and patient are
included in the time out.
Only in urgent situations.
Is there a standard communication
method that you use when you are giving
report or calling a physician about a patient?
SBAR
Show me the pre-op checklist and
describe process
SDS nurse completes and is available
for 1:1 with OR nurse if questions
arise.
Tracer Tips
Examine any informed consents in the
record for completion and agreement with
process stated by staff member.
Surgeon marks the site with his initials
before the patient goes to the OR/procedure
room
Site should be marked by anesthesiologist
and time out should be done
Override is used in urgent/emergent
situations. The situation, not the medication
determines if override is appropriate.
Response should refer to SBAR
OR Nurse
Questions / Actions
What is your process for informed
consent?
Who marks side/site?
How is the site marked?
When is the site marked?
Where is the time out documented?
When is the time out done?
Who is present for time out?
Notes/Deficiencies Identified
Surgeon explains the surgery risks,
benefits, and alternatives. Nurse
“witnesses” the patient’s signature.
Any questions—nurse contacts the
surgeon to answer.
Surgeon marks the site before patient
gets to OR.
Tracer Tips
Examine any informed consents in the
record for completion and agreement with
process stated by staff member.
Surgeon marks the site with his initials
before the patient goes to the OR/procedure
room
Documented in the intraoperative
nursing record
Time out done immediately prior to
incision
Nurse named all but anesthesia
provider
Circulator labels meds when they are
drawn up. All containers are labeled
too.
Response should indicate time out is done
immediately before start of procedure and
that all members involved in procedure are
present—including the physician and
anesthesiologist.
Questions / Actions
Give me an example when you would use
override (Pyxis).
Notes/Deficiencies Identified
To get anti-nausea drugs for patients
when they return from surgery
Tracer Tips
Override is used in urgent/emergent
situations.
The situation, not the medication determines
if override is appropriate.
What is your policy for range orders?
Start with the lowest dose ordered and
work up if necessary
For any range order found, ask staff
member how he/she would implement the
order.
Describe how you assess the post op patient
for pain and how you determine what/when
to give.
Do you use pain scales?
How would you assess for pain in a nonverbal patient (infant, child, adult)?
How do you document effectiveness of pain
treatment?
What is the time frame for reassessment?
Usually assess pain by patient’s
facial expressions and behavior since
they are coming out of anesthesia.
Once more awake, will use 0-10 scale.
Reassessment done within 1 hour or
sooner and prior to any other pain
med being given.
Medication labeling—
Who labels medications that are used during
surgery?
Describe process for labeling
Label one at a time, at the time the med is
prepared/poured.
Containers must be labeled.
Original container should not leave the room
or be discarded until case is over.
PACU Nurse
Nightingale Community Hospital
It’s how we treat you.
Our Care
Nightingale Community Hospital provides leadership in
quality health services. We also provide compassionate and
cost-effective service in the lines of treatment and
prevention.
Our vision is to be the hospital of choice for patients,
employees, physicians, volunteers, and the community.
Our mission is to create a healing environment, with a
passionate commitment to healthcare excellence.
Our patients see our passion the moment they walk in the
door. From reception to discharge, we treat you well.
The future depends
on what we do in the present.
Mahatma Gandhi
How We Treat You
Nightingale Community Hospital is a 180-bed, acute care,
not-for-profit community hospital. We provide services in
these areas:
General Medical/Surgical Services
We partner with our state’s Surgical Care Initiative (SCI) to
provide the best care possible. To locate a doctor that’s right for
you, call 555-0988.
Critical Care & Emergency Services
Our ER service has recently won a SCOPE award for best
customer service in an ER. Visit us and see why! Call 555-0987 for
more details.
Oncology
Our oncology services are second to none. We understand how
cancer affects the whole family, so we provide comforting suites
for service, with attention to patient comfort and effective
treatment. To start your journey to wellness, call 555-6785.
Cardiology
Services include a dedicated cardiac catheterization lab, sameday diagnostic procedures and the only nationally certified
cardiac rehab program in Spring County. Call us at 555-3456 to
schedule your heart.
Neuroscience Unit
The inpatient acute care Neuroscience Unit at Nightingale’s cares
for patients who are being treated with surgery or medicine for
brain injury, spinal injury, stroke, trauma, multiple sclerosis, ALS,
Alzheimer’s disease, and seizures related to neurological
disorders.
Orthopedics
A total renovation of this unit last year transformed it into a
warm and healing environment for patients and their visitors.
Caregivers on this unit are specially trained to care for patients
who have had orthopedic surgeries. And they continually finetune their skills by caring only for orthopedic patients.
Imaging Services
Our imaging equipment includes MRI, PET-CT, and CT Scans that
allow us to record your health, diagnose the problem and plan
medical treatment with you.
Obstetrics
Obstetric services at Nightingale’s combine the talents of
hospital-based and community specialists to bring complete care
to our patients. Our broad range of programs and expertise help
women prepare for pregnancy, then guide them through both
routine or high risk pregnancies to the birth of the baby. Special
attention is given to meeting the family’s expectations of the
birthing process.
Level II Nursery
Specially trained physicians and nurses provide care 24 hours a
day in the Telemetry Care Unit, which assists patients who need
specialized cardiac care and monitoring.
We understand that you want the best possible care for your
baby. The good news is that Nightingale’s offers a Level II
Neonatal Intensive Care Nursery. This means that we can take
care of newborns with a wide variety of special care needs,
allowing mother and baby to stay in the same hospital.
Vascular Lab
Endoscopy and Surgery
The Noninvasive Vascular Laboratory (the “Blood flow lab”) is
one of the key components of the Nightingale Vascular Lab.
Noninvasive testing, as the name implies, allows patients to be
examined using Doppler ultrasound techniques free of the risks
and discomforts of injections and/or other invasive maneuvers.
Our highly trained staff of registered nurses and technicians are
cross-trained in all areas of Endoscopy Services.
Telemetry Care
Our Values
We expect of ourselves, and pledge to our communities, a
commitment to four core values:
Safety
We believe that excellence begins with providing a safe
environment. We put our patients first as we seek to
exceed the expectations of our customers with superior
service, outstanding clinical care and unsurpassed
responsiveness.
Community
We reach beyond our walls to engage in partnerships that
improve the education and healthcare needs of our
community. We invest in the community by continually
improving services and broadening our spectrum of care.
Teamwork
We collaborate with others for the benefit of all. We
acknowledge differences among people and recognize
strength of diversity.
Accountability
We provide cost-effective, quality services; we foster the
financial strength, stability and growth of Nightingale’s;
and we support individual initiative and innovation.
The sum of the whole is this:
walk and be healthy.
Charles Dickens
Safety Reports
NPSG 1: Improving accuracy of patient identification
Opportunities for improvement—use of two patient
identifiers and labeling of specimens in the presence of
the patient
NPSG 2: Improving effectiveness of communication—
Critical Results
Hospital-wide Compliance of Reporting Critical Results
within 60 Minutes as Evidenced by Documentation
NPSG 2: Improving effectiveness of communication—
Verbal Orders/Read-backs
NPSG 2: Improving effectiveness of communication—
Unacceptable Abbreviations
99.6%
NPSG 3: Improving safety of using medications—
Labeling of containers
NPSG 3: Improving safety of using medications—
Reduce the likelihood of patient harm associated
with the use of anticoagulation therapy
NPSG 7: Reduce the risk of health care-associated
infections—Hand Hygiene
Hand Hygiene Compliance
92
100
93
80
60
40
54
46
20
0
Year 1
Year 2
Year 3
Year to Date
NPSG 9: Reduce the risk of patient harm
resulting from falls
Universal Protocol
Joint Commission Survey Results
2 years ago
PC.01.03.01
Care and treatment are planned to ensure that they are appropriate to the patient’s needs and
severity of disease, condition, impairment, or disability. Care is planned and provided in an
interdisciplinary, collaborative manner by qualified individuals.
Finding
On interview with the care team, there appears to be an interdisciplinary, collaborative process
in place within the hospital. This process, however, does not generate an interdisciplinary plan
of care. There was insufficient evidence that care goals were prioritized based on the patient’s
progress. The patient’s progress should periodically be evaluated against care goals and the
plan of care and, when indicated, the plan or goals should be revised.
PC.01.01.07
Pain is assessed in all patients.
Finding
In outpatient rehabilitation, the initial assessment of pain does not indicate the severity of the
pain, making assessment of the relief of pain as a result of treatment difficult.
PC.02.03.01
The hospital provides patient education and training based on each patient’s needs and
abilities.
Finding
When visiting the oncology clinic, it was noted that the medical record of the clinic patient did
not contain documented evidence that the patient’s ability/readiness to learn, learning
preference, or educational needs were assessed. The closed and open medical records reviewed
in the hospital lacked sufficient evidence that the individual’s ability to learn, prior to the
provision of education, was assessed.
RC.02.01.03
The patient’s medical record documents operative and other high-risk procedures and the use
of moderate or deep sedation or anesthesia.
Finding
An operative progress note was not evident in 2 of 21 closed medical records.
LD.04.01.05
The hospital effectively manages its programs, services, sites, or departments
Finding
It was evidenced through interview with three staff nurses that the leaders had not effectively
communicated to the nursing staff the policy related functional screening criteria. Interview of
three staff nurses revealed that they were not aware of the functional screening process the
hospital had implemented.
PC.03.01.01
The hospital plans operative or other high-risk procedures, including those that require the
administration of moderate or deep sedation or anesthesia.
Finding
Two medical records of patients who had undergone cardiac catherization did not contain
documentation that the patients were reevaluated immediately before the administration of
moderate sedation. In addition, a medical record of a patient receiving care in the endoscopy
area was reviewed. This record review also indicated that the patient was not reevaluated
immediately prior to the administration of moderate sedation.

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