Accreditation Audit Task 1

1732 Words Sep 5th, 2014 7 Pages
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 includes medical professionals as well as friends and family to compliment each other in providing for patient needs. Because patients require care from medical professions in hospitals, there are provisions that the hospital must follow.
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However, documenting the completion of a “time out” is met by the Universal Protocol Policy but also has the added benefit of being stated in the Pre-procedure handout. Upon conduction the accreditation audit for marking the procedure sites, Nightingale Community Hospital has policies in place to make sure they are being met.

The final standard under communication is the performance of a “time out” before a procedure. There are also elements of performance that must be met to be in compliance for this standard. The first is conducting a “time out” before every procedure. This is met by the Universal Protocol Policy. The Universal Protocol Policy also meets the next bullet point of standardizing “time out” for Nightingale Hospital and having them started by an elected team member with the involvement of team members. The third element of performance is performing a “time out“ between a change of people performing a procedure on a patient. This is unfortunately not met by any protocol in the information provided by Nightingale Hospital. Having team members agree the correct patient identity, the correct site, and the correct procedure to be done on a patient is the next element of performance. The final element of performance is the documentation of “time outs”. Though there are no policies bases on the information given from Nightingale Hospital of “time outs”, there is a graphical analysis of “time outs” hospital wide indicating

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