Accreditation Audit Essay

1597 WordsJan 16, 20137 Pages
Accreditation Audit RAFT Task 1 Executive Summary Nightingale Community Hospital (NCH) is a hospital that states they are leaders in quality healthcare. To remain a leader in hospital care it is crucial for the hospital to adhere to standards developed by the Joint Commission Accreditation on Healthcare Organizations (JCAHO). JCAHO is the organization that accredits and certifies hospitals that meet certain performance standards nationally. Only those hospitals that have the JCAHO accreditation are ensured to be in compliance with specific guidelines in each Priority Focus Areas: Infection control, Communication, Medication Management, and…show more content…
In the second Element of Performance, JACHO names each team member of the team while NCH’s policy only says all members of the team leaving it uncertain who is part of the team. In compliance with JACHO, NCH fails to comply with the third Element of Performance in that they have no policy stating that a separate time-out needs to be initiated if the patient is having two or more procedures and the person performing the procedures changes. A1. Plan for Compliance Nightingale Community Hospital has some adjustments to make to their current policy relating to the PFA of Communication to ensure that they are compliant with JCAHO’s standards. Suggested adjustments for each standard to meet JCAHO standards: UP.01.01.01: Conduct a pre-procedure verification process. 1. Revision to NCH Hand-off form to include an area for the patient’s name, the specific procedure and exact site. 2. To comply with the second Element of Performance additional data needs to be added to the Hand-off form stating equipment needed for the patient’s procedure and an initial for noting that the equipment was matched with the patient. UP.01.02.01: Mark the procedure site. 1. NCH policy has an extensive list of site markings, however the area stating that breasts needle localization may be used to identify breast lesions is stated

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