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Nightingale's Compliance Case Study

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A1. Compliance Status Concerning Nightingale Community Hospital's Compliance, one of the areas requiring improvement is in 3-East. The leadership in 3-East is has been discovered outside of acceptable compliance. According to the FCA findings, working overtime, low morale and on-time reporting is causing issues. The five areas the Joint Commission notes as key to effective performance is not being utilized in 3-East. This is a result of not applying data to plan, communicate to improve performance and effect staffing accordingly. On the positive side, the following are areas we are in compliance. Accreditation participation requirements (APR) certifies that Nightingale is following protocols and procedures to deliver safe and quality …show more content…

We have established a comprehensive Emergency Operations Plan to handle our resources to provide safe environment for our patients in the event of adverse conditions such as power failures, water, fuel shortages, flooding, and communication breakdowns. Our facilities are prepared, staff knows responsibilities to extend patient care under disrupted utilities and other emergency situations. Human resources (HR) department is fully in compliance for meeting all requirements. HR is critical to Nightingales success in making sure of the quality of our staff, talents, training and education to provide the best care possible for our patients resulting in our good credibility. Nightingale's Infection Prevention and control (IC) meets compliance requirements. Therefore our hygiene protocols are being followed by our staff. Staff is collaborating with each other to ensure infection prevention and control program by using surveillance, data collection, analysis, and trend identification to maintain and sustain a safe environment. Performance Improvement (PI) is another area we are in compliance. Therefore our base line data has been effectively analyzed to determine trends, patterns and exposed areas for making improvements. The result has been good services, treatment and care for our

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