Continuous Accreditation Compliance - Task 4 AFT2 Accreditation Audit October 31st, 2014 Continuous Accreditation Compliance - Task 4 Nightingale Community Hospital (NCH), like many other health care facilities, uses a Periodic Performance Review (PPR) as an assessment tool that assists in examining performance on a consistent basis to ensure compliance with Joint Commission standards. A PPR concentrates attention on procedures, methods, and processes that contribute an environment…

RAFT Task 1 Executive Summary By Cindy Granger December 1, 2011 Mission: To implement a corrective action plan in the area of Communication for Nightingale Community Hospital as required for Joint Commission Compliance. Corrective Action Plan: Standard: UP.01.01.01: Conduct a Preoperative Verification Process. At the present time Nightingale Community Hospital is not in compliance with rule UP.01.01.01. Nightingale currently has a five step verification process in regards to Preoperative/Pre-procedure…

Preprocedure Hand-off will be updated and reviewed by the facility’s Compliance Department • Mandatory in-services of all pre-op and surgical team will be conducted in regards to updated processes • Three monthly audits to be conducted regarding updated processes • Quarterly audits to be conducted for each of the above specific standards, rotating one each quarter • Mandatory yearly in-services to be conducted for each of the above specific standards in its entirety (not only the updated processes)…

Running head: ACCREDITATION AUDIT- TASK 4 COMPLAINCE STATUS Joint Commission clearly explained that a Periodic Performance Review is as an assessment tool designed to help in assisting the healthcare organization contributes greatly in the improvement and monitoring performance all through the year. The periodic performance focuses more on the measures that has to do with patients safety and care and at same time given the facility for unremitting standards fulfillment. NCH is 100% compliance with…

Executive Summary of Accreditation Audit June 2012 I prepared and reviewed an accreditation audit for Nightingale Community Hospital to organize and ensure compliance with Joint Commission standards for our hospital. We are preparing for a site visit that should occur within the next 13 months. I have reviewed the current compliance status of our hospital and will explain our corrective action plan that will ensure compliance with the Joint Commission standards for the focus area of communication…

Hospital is compliant with most standards as set forth by the Joint Commission. However, upon inspection and in an effort to stay focused on compliance, our standards committee has located a few discrepancies that must be resolved to maintain our accreditation with the Joint Commission. Rather than focus on the discrepancies found within each unit, we will look at the trends that affect the hospital’s compliance with the Joint Commissions recommendations regarding patient care. Armed with the trends…

Accreditation Audit Task 1. A1. Communication, this is the key focus area that is evaluated in this summary. Communication is a key focus area of the joint commission audit and is also a key area in which Nightingale Community can make enhancements. Communications must be a two way free flow of information. The information exchanges occur between providers, staff, and patients or clients. This was an area that needed improvement was noted in the previous accreditation audit. Some noted prior…

Accreditation Audit Task 1. A1. Communication, this is the key focus area that is evaluated in this summary. Communication is a key focus area of the joint commission audit and is also a key area in which Nightingale Community can make enhancements. Communications must be a two way free flow of information. The information exchanges occur between providers, staff, and patients or clients. This was an area that needed improvement was noted in the previous accreditation audit. Some noted prior…

1. Compliance Status Following rules and regulations is important for institutions and any type of establishment to maintain organization and most importantly provide safety for those involved. For the organization and safety of everyone involved, it is important to comply with particular criteria. Hospitals are one of the many organizations that must comply with regulations to keep patients and staff safe and as well as maintain the quality of care. Ideally, a good care system for patients…

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…