Est1 Task 3

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A1. Status 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: Compliant: Emergency Management Human resources Infection Prevention and Control Performance Improvement Right and Responsibilities of the Individuals Transplant Safety Waived Testing Non- Compliant Environment of Care Leadership Life Safety Medication…show more content…
Mandatory in-services and mandatory weekly audits will be initiated in all areas of non-compliance. Chart reviews, audits and surveys of the staff allow directors and administration to evaluate the required in-services and education provided to staff in regards to the current non-compliant areas. Addressing hospital wide issues with visual reminders and cues. The increase audits and chart reviews will be initiated until the compliance level of “ORXY initiative” is within The Joint Commission requirements of 85% (Commission, 2013). A3a. Staffing Pattern Providing the best care to each patient starts with providing the proper amount of staff members to each unit. Looking at the needs of different units not only allows administration to see areas for improvement, but also areas that are being handled correctly. Utilizing the indicators provided by The Joint Commission, 4 East, a pediatric medical/surgical floor, has a high rate of falls and nosocomial pressure ulcers that appears to be related to the increase overtime nurses have been working for that floor (Nightingale, 2010). Research has shown increases in adverse events have been related to nurses working over 40 hours a week (Bae, 2012). The clutter in the hallway needs to be addressed for the safety of patients, visitors, and nursing staff. This will also improve the efficiency of the staff by removing barriers to traffic flow. The nursing staff will be able to
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