Accreditation Audit Task 4

2231 Words Jul 24th, 2012 9 Pages
COMPLAINCE STATUS

The Joint Commission defines the Periodic Performance Review as an assessment tool created to assist health organizations improve and monitor their performance throughout the year. This tool focuses on the processes that influence patient care and safety while providing the structure for unremitting standards fulfillment. Nightingale Community 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
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The hospital policy for fire drills requires one drill per shift per quarter. The audit shows that there are some compliancy concerns regarding the fire drills. During third shift, for the first and third quarters, no fire drill occurred. Also, there was no fire drill on the second shift during the fourth quarter. Obviously, there should be further study to determine the cause for the compliancy issue vs. staffing deficiencies during third shift. Additionally, each department will have a safety monitor assigned to ensure the fire drills occur as per hospital policy. The safety monitor will complete a form documenting the staff involved in the fire drill, date, and time the drill took place and will keep a copy in the safety manual to be inspected monthly.

Other safety concerns that were identified during the PPR rounds include clutter in the hallways, smoke wall penetrations, master alarm panel for medical gasses was not tested, and the gift shop did not have the required 18” clearance from the sprinklers. The maintenance department manager will need to implement a corrective action plan and be held accountable for the discrepancies identified.

Additionally, the Moderate Sedation Monthly Audit of the Endoscopy Department shows some compliancy issues regarding pre-procedure events. Mallampati classification, ASA, Sedation plan documentation, and completion of reassessment are consistently below 90% for all

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