Accreditation Audit – AFT2, Task 1
Western Governors University
, Executive Summary
In this document, you will find a review of Nightingale Community Hospital’s
Site Identification and Verification (Universal Protocol) policy under The Joint
Commission Element of Performance (EP) under National Patient Safety Goals
(NPSG) UP01.01.01, UP01.02.01, and UP01.03.01. All three standards were
found to have one element out of compliance. It is noted that the Nightingale
Community Hospital Surgery Leadership Committee has taken time and
consideration when drafting this policy.
This report serves as a tool to bring the Hospital into compliance for a Joint
Commission review and details the noncompliant elements and an action
plan to remedy the deficiencies. This document references the Site
Identification and Verification (Universal Protocol) policy and the
Preprocedure Hand-Off checklist as proof of compliance.
A: Compliance
UP01.01. Conduct a pre-procedure verification Compliance
01 process. Rating
1 Implement a pre-procedure process to Compliant
verify the correct procedure for the correct
patient at the correct site.
2 Identify the items that must be available Not Compliant –
and use a standardized list to verify The policy does
availability. not address
identifying items
necessary for the
procedure
UP01.02. Mark the procedure site Compliance
01 Rating
1 Identify procedures required to mark Compliant
incision/insertion site.
2 Mark the procedure site before the Compliant
procedure is performed and.
3 The procedure site is marked by a licensed Not Compliant –
practitioner who is accountable and The policy does
present for the procedure. not identify the
individual
responsible for
marking procedure
sites
Western Governors University
, Executive Summary
In this document, you will find a review of Nightingale Community Hospital’s
Site Identification and Verification (Universal Protocol) policy under The Joint
Commission Element of Performance (EP) under National Patient Safety Goals
(NPSG) UP01.01.01, UP01.02.01, and UP01.03.01. All three standards were
found to have one element out of compliance. It is noted that the Nightingale
Community Hospital Surgery Leadership Committee has taken time and
consideration when drafting this policy.
This report serves as a tool to bring the Hospital into compliance for a Joint
Commission review and details the noncompliant elements and an action
plan to remedy the deficiencies. This document references the Site
Identification and Verification (Universal Protocol) policy and the
Preprocedure Hand-Off checklist as proof of compliance.
A: Compliance
UP01.01. Conduct a pre-procedure verification Compliance
01 process. Rating
1 Implement a pre-procedure process to Compliant
verify the correct procedure for the correct
patient at the correct site.
2 Identify the items that must be available Not Compliant –
and use a standardized list to verify The policy does
availability. not address
identifying items
necessary for the
procedure
UP01.02. Mark the procedure site Compliance
01 Rating
1 Identify procedures required to mark Compliant
incision/insertion site.
2 Mark the procedure site before the Compliant
procedure is performed and.
3 The procedure site is marked by a licensed Not Compliant –
practitioner who is accountable and The policy does
present for the procedure. not identify the
individual
responsible for
marking procedure
sites
