Identify A TJC Safety Goal Relevant To An Area Of Care

Identify a TJC safety goal that is relevant to an area of concern at your place of employment or clinical rotation

Identify a TJC safety goal that is relevant to an area of concern at your place of employment or clinical rotation. Describe a situation in the workplace or nursing practice that needs change. Then, following the instructions and using the fishbone diagram template found in course documents, complete a Root Cause Analysis of your identified problem. Attach your fishbone diagram to your discussion board post. The root cause analysis allows improvement teams to identify the “root” of the problem, where and why the problem exists.

Improvement teams make decisions based on data rather than “hunches” and look for lasting solutions rather than relying on “quick fixes” and “band-aid” approaches. Identify a problem. Consider all factors of the problem, such as, “we do not perform adequate pain assessments because…” Once all factors causing the problem are identified, it should be evaluated and grouped in categories. Then a “cause and effect” diagram, such as a fishbone diagram, can be created. General categories may include Environment, Equipment, People, Methods (process), and Materials.

Attach your fishbone diagram to your discussion board post. Using the template found in the "resources" tab, complete a fishbone diagram of your identified problem. The cause and effect diagram (fishbone) starts with a problem at the head of the fish. Under each general category of the fishbone, answer the questions, “Why?” in regard to the problem identified. Once the fishbone diagram is done, the various causes are discussed to determine the root of the problem. The results of this discussion drive the focus for the improvement plan.

There may be several causes of the problem. The team should prioritize which one cause, if solved, would have the most positive impact on the largest number of residents. Also, see some useful document attached below.

Paper For Above instruction

In healthcare settings, patient safety is paramount, and the Joint Commission (TJC) has established critical safety goals aimed at improving patient outcomes and minimizing errors. One pertinent TJC safety goal is the reduction of healthcare-associated infections (HAIs), such as catheter-associated urinary tract infections (CAUTIs). During my clinical rotation in a surgical ward, I observed a concerning trend where patients with indwelling urinary catheters were developing infections at alarming rates. This situation highlighted a need for targeted intervention aligned with the TJC goal to reduce HAIs by implementing best practices for catheter care and infection control.

The identified problem was the frequent occurrence of CAUTIs, which compromised patient safety and prolonged hospital stays. A root cause analysis using a fishbone diagram was performed to identify the underlying causes of this problem. The categories considered included People, Environment, Equipment, Methods, and Materials. Under each, specific causes were identified and analyzed.

For instance, under People, staff nurses lacked consistent education on aseptic techniques during catheter insertion and maintenance. This was confirmed by observing irregular hand hygiene practices and insufficient training documentation. Under Environment, high patient turnover and overcrowding led to rushed procedures, increasing risk. Equipment issues included inadequate sterilization of catheters and storage problems leading to contamination. Methods factors involved inconsistent protocols for catheter insertion and maintenance, as well as lack of adherence to evidence-based guidelines. Materials included shortages of sterile supplies, leading staff to improvise or reuse equipment, thereby increasing infection risk.

By evaluating these causes, the analysis revealed that staff training and adherence to infection control protocols were pivotal. The root cause was primarily a deficiency in ongoing education on infection prevention measures, compounded by systemic issues like staffing shortages and resource limitations. This was prioritized because addressing staff education would directly influence proper catheter care practices, thus significantly reducing CAUTI incidence across the unit and improving overall patient safety.

Based on this root cause analysis, a comprehensive improvement plan was devised, including regular staff training sessions, strict adherence to CDC guidelines, and improved supply management. Continuous monitoring and feedback loops were also established to sustain improvements. This approach demonstrates how systematic analysis rooted in data can lead to lasting safety improvements, aligning with TJC safety goals and enhancing the quality of care provided to patients.

References

• Centers for Disease Control and Prevention. (2020). Guideline for the prevention of catheter-associated urinary tract infections (CAUTI). CDC.
• Joint Commission. (2021). National Patient Safety Goals. The Joint Commission.
• Gould, C. V., Moralejo, D., Drey, N., & Chudleigh, J. (2014). Strategies to reduce urinary catheter use in hospitalized patients. The Cochrane Database of Systematic Reviews, (11), CD008225.
• Saint, S., et al. (2016). Preventing catheter-associated urinary tract infection in the ICU setting: a systematic review. Journal of Critical Care, 36, 107-113.
• Hooton, T. M., et al. (2010). Long-term antimicrobial prophylaxis for recurrent urinary tract infections in susceptible women. JAMA, 304(18), 2000-2001.
• Siegel, J. D., et al. (2007). Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. CDC.
• Robertson, M., & Simmonds, M. (2016). Education and training for healthcare staff in infection prevention. Journal of Nursing Education, 55(9), 511-514.
• Larson, E. (2013). Hand hygiene and skin integrity: core components of infection prevention. Infection Control & Hospital Epidemiology, 34(11), 1077-1084.
• Whitfield, T., et al. (2018). Environmental factors influencing infection rates in hospitals. American Journal of Infection Control, 46(9), 1007-1012.
• Hansen, D., et al. (2020). Improving compliance with infection control procedures: a quality improvement approach. BMJ Quality & Safety, 29(5), 393-400.