Accreditation Audit Task 4

Preparing for The Joint Commission, Nightingale Community Hospital reviews areas of compliance and non-compliance. A periodic performance review, which is a self-evaluation, is utilized by Nightingale Community Hospital, to prepare for The Joint Commission. The Joint Commission has eighteen accreditation requirements. (Commission, 2013) The periodic performance review found the hospital to be compliant and non- compliant in the following areas:

In accordance with this the hospital makes sure we follow guidelines laid down by Joint commission Standards. The compliance includes four areas…Information management, Infection control, Communication and Medication Management. The Goal here is patient safety and providing patients with safe and effective care of the highest quality and value.

The Priority Focus Area of Communication includes 3 Joint Commission (JC) standards relative to Universal Protocol. These 3 standards, which are components of the National Patient Safety Goals, are aimed at ensuring the correct

There are two prohibited abbreviations that are tracked, “cc” and “qd”, as they are the most common. Throughout the year there has not been consistent improvement in the area. The trending data shows some improvement in parts of the year and then some months, April and September, to have increased spikes of use of prohibited abbreviations. During the PPR it was noted that the following departments were non-compliant concerning using prohibited abbreviations: 3E, 4E, ICU, and Telemetry. The

Health care organizations generally volunteer to seek accreditations from the Joint Commission by allowing expert surveyors evaluate their facility. The surveyors are made up of a multi-disciplinary team that spends an average of two days inspecting health care facilities. The purpose for the inspection is to evaluate a health care facilities standards, staff, regulations, policies and procedures, and quality improvement, and performance measurement. The Joint Commission surveyors generally look to see if the organizations governing board is taking part in ensuring that the facilities has facilitated safety and quality assurance program.

A.Nightingale Community Hospital is attempting to be in complete compliance with Joint Commission’s “communications” standards. Prior to the Joint Commission survey, Nightingale Community Hospital wanted to focus on items UP.01.01.01 through UP.01.03.01 of the Joint Commission handbook. According to the handbook, these items focus on the universal protocols for preventing wrong site, wrong procedure, wrong person surgery (2015). In response to these universal protocols, the hospital implemented a pre-procedure hand-off tool, which is completed and signed off by both the nurse handing off the patient as well as the nurse accepting the patient. The hospital also began

The purpose of this report is to summarize, analyze and evaluate the compliance status of Nightingale Hospital to Joint Commission requirements. This report will focus on medication management, specifically anticoagulation therapy and the patient and staff education associated with it. In an effort to maintain the highest quality of care for our patients, we must continue to work towards a reduction in adverse anticoagulation related events. This will involve proper pre-discharge

The verbal order read back initiated by the hospital has improved with all but one department exceeding a 90% ratio. This will be a focus area for the Ortho department, as they will have a goal to reach of exceed 90% within the remaining accreditation period. We will continue to quantify the results of all departments monthly as well as evaluate the Orhto department to determine if there are any roadblocks to attaining the improvement goal. The second lowest score is currently being achieved by the surgical unit although they are doing well we will target this department for ongoing training. All departments will continue to receive documentation and training in this area.

5. The Patient Safety Officer will train the risk assessment team members on the proactive risk assessment process and how to conduct a proactive risk assessment, including the assessment of risk, itself.

The importance of receiving accreditation from the Joint Commission is critical for medical facilities because it represents high standards of quality assurance which

The first spoke, “adherence to code for nurses,” represents the need for nurses to follow the rules laid out for them. These could be scope of practice, rules associated with certain workplaces and following proper procedures. To be professional, a

The CNO outlined professional standards for nurses to comply with. The seven that are outlined are accountability, continuing competence, ethics, knowledge, knowledge application, leadership, and relationships. “A standard is an authoritative statement that sets out the legal and professional basis of nursing practice” (College of Nurses of Ontario, 2009, p. 3). Although each standard has different meaning, they all work together in order to provide the best possible patient care.

Nightingale Community Hospital (NCH) has thirteen months until their next Joint Commission audit. This report will evaluate Nightingale Hospital’s compliance in The Priority Focus Area of Communication using the Universal Protocol Standards from the Joint Commission Handbook. “The Universal Protocol was created to address the continuing occurrence of wrong site, wrong procedure and wrong person surgery and other procedures in Joint Commission accredited organizations” (Joint Commission, 2013).

Improving patient health is the main objective for every healthcare provider and setting. To attain this goal, they use some standards to represent the information needed. Thus, accurate health information is crucial to provide the appropriate treatment to a patient that is hospitalized. The use of health information standard represents the essential to patient safety. This application will describe the standard used in the case of a hospitalized patient through various scenarios.

Dr. David Torchiana (Cardiac Surgeon) and Dr. Richard Bohmer (Quality Improvement Administrator) want to improve the process in the hospital by