Executive Summary

1440 Words Feb 17th, 2014 6 Pages
Executive Summary - Infection Control and Prevention Current Compliance Status for Joint Commission Accreditation
Nightingale Community Hospital is committed to providing healthcare excellence, a healing environment and to be the choice for patient care. In order to continue to provide quality healthcare services in accordance with our values of safety, community, teamwork, and accountability Joint Commission Accreditation provides guidelines and standards for the Priority Focus Areas (PFA) for the welfare and quality of patient care.
Infection control and prevention extends beyond treating the patient. It encompasses all who work and visit the facility including medical staff, administrative staff, volunteers, vendors, and
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These policies and practices meet regulatory requirements and are aligned with evidence-based standards
8. Implement a laboratory-based alert system that identifies new patients with MDROs.
9. Implement an alert system that identifies readmitted or transferred patients who are known to be positive for multidrug-resistant organisms.
Corrective Action Plan
Perform quarterly risk assessments of MDROs transmission and acquisition.
Provide annual educational seminars to staff and practitioners regarding the transmission, reduction, control, and prevention of HIAs based on the quarterly risk assessment outcomes.
Focus on family and patient education to bring awareness of reduction, prevention, and treatment of MDROs.
Healthcare-associated infections (HAI) surveillance should identify the population who are of greater risk for contraction or transmission of MDROs over a 12- month period.
During the monitoring period treatments and outcomes should be measured to determine the effectiveness and adherence of protocols.
Monitor isolation to assess risks.
Prepare quarterly reports to key stakeholder regarding HIAs monitoring, protocols, and outcomes.
Review and incorporate evidence-based standards to reduce, prevent, and treat HIAs that meet regulatory standards from organizations such as Center for Disease Control (CDC), Department of Health and Human Services (HHS), and World Health Organization (WHO).
Implement real-time

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