Nightingale's Compliance Case Study

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:

The HR department officials in most organizations perform as they should. In most cases, they also focus on achieving the right things. Human Resource departments focus organizing, controlling, and hiring employees in organizations. When organizations apply HR practices, the results are great client satisfaction, a good net margin, and reduced sickness absence (Richard and Johnson, 2001). Vermeeren et al. (2014) posit that there is a great relationship between performance and HRM. Most organizations use the human resource department to ensure that operations run smoothly.

The Joint Commission is scheduled to visit Nightingale Community Hospital for its triennial accreditation survey within the next 13 months. The purpose of this document is to provide senior leadership with an outline of the hospital’s current compliance status in the Priority Focus Area of Communication. Recommendations for corrective action are included in this document which are designed to bring the organization into full compliance in the areas where deficits have been identified.

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.

Communication, this is the key focus area that is evaluated in this summary. Communication is a key focus area of the joint commission audit and is also a key area in which Nightingale Community can make enhancements. Communications must be a two way free flow of information. The information exchanges occur between providers, staff, and patients or clients. This was an area that needed improvement was noted in the previous accreditation audit. Some noted prior issues from 2 years ago included patient and family education and information not being properly disseminated to the nursing staff. These are areas where we have targeted and currently meet. Some areas that we continue to work on are as follows.

The four main areas of focus for the Joint Commission for Nightingale Hospital include Communication, Information Management, Medication Management and Infection

In day to day operations, uncertainties do occur. Henceforth it would be important to have a contingent and well detailed disaster preparedness plan and procedures. Healthcare systems, on a day to day basis, are faced with emergencies in form of disasters. As a result, majority of medical centers have well-structured exit plans in the event of a disaster occurring("Hospital Disaster Preparedness: Your Guide to Getting Started - Emergency Preparedness", 2011). However, this essay will aim at interviewing one of the top disaster preparedness staffat the Houston Methodist Hospital. In the interview, I will seek to identify the top three disasters that the Houston Methodist Hospital is prepared for. Similarly, in the interview, I would seek to identify the top lessons learnt from disaster preparedness at the hospitals.As it concludes it would summarize the findings with regards to the interview stated below. Below is an excerpt from the interview to answer the two aforementioned questions.

According to the Texas Health Presbyterian Denton Emergency Operations plan their objective “is to maintain the continuity of patient care operations and meet the medical needs of our members and the community.” In order to accomplish this goal they assert that maintaining the safety and security of the organizations staff and volunteers is the top priority, as the safety of their staff ensures they will be able to accomplish their mission of providing care for patients, visitors, and the larger community. In addition to their primary goal, they have also identified a secondary objective of providing supplies and assistance to other Texas Health facilities.

In order to provide cost-effective quality services, information must be accurate and communication of the information should be securely transmitted in a timely manner to the appropriate individuals on a need to know basis. The Nightingale Community Hospital current compliance status is not fully meeting the standards of the Joint Commission. The hospital is in compliance by measuring the delinquency regularly on a monthly basis as evidenced by NPSG 2 and 3 chart base on adverse drug events related to anticoagulation therapy, medication labeling, reporting critical results, time-out, and inpatient falls. The medical record delinquency rate average is less than 50% of the average monthly discharge rate therefore the hospital

Research shows that Surgical site infections are preventable. According to the CDC, hand hygiene is the simplest approach to preventing the spread of infections and needs to be incorporated into the culture of the organization. Ensuring the use of infection control prevention is an important component of nursing care. Infection control prevention policies must be communicated undoubtedly to all employees. Staffers who do not comply must be re-educated to ensure that all are complying. Speaking up and pointing out that a nurse forgot to wash his or her hands, or notifying the surgical team that surgical instruments were not adequately cleaned may seem like small issues; but at the same time, not acknowledging a break in a sterile technique could mean the difference between life and death for a patient. One hospital that was struggling with high levels of infection related to surgical procedures, implemented a pre-procedure huddle as a team. This innovate way decreased the spread of infection and was a great way to improve the quality of care for patients. As mandated by the Joint commission, infection prevention personnel should provide multidisciplinary education on SSI prevention, to all team members, including

I feel that when discussing a person’s compliance or adherence to a healthcare plan it can seem very black and white. In order to gain a better perspective on what I mean I am going to define each key term. Compliance is identified as someone who is obedient and accepting of their healthcare treatment plan, whereas adherence is referred to as showing commitment and support of a plan of care (Richards, 2014, p. 219). My patient has struggled with compliance to her health regime. I do not think this is because she chooses to be noncompliant. Instead, I attribute it to the Biomedical theory, which identified several factors including, “demographics, severity of the disease, and complexity of the treatment” (Richards, 2014, p.219) to her compliance

To explain the influence of Nightingale’s theory in the promotion of a multidisciplinary team, an article written by Zborowsky (2014) will explore the legacy of Florence Nightingale in relation to the nursing research about the impacts of the healthcare environment. Creating a healthy working environment has been an ongoing focus for many organizations ever since the Institute of Medicine (IOM) made a public disclosure of medical errors in 2000, as reviewed by Zborowsky (2014). From the IOM 2004 report and Robert Wood Johnson Foundation (RWJF) 2010 article, Zborowsky (2014) cited that the poor environmental design affected the quality patient care and nurses’ work performance. Aside from these reports, Zborowsky (2014)

Report for priority focus area under infection control standard, for Nightingale Community Hospital. Our hospital is 13 months away from its anticipated next Joint Commission visit (JAHCO).

1.The main roles and responsibilities of the employee in relation to prevention and control of infection are as follows:

The importance of human resources to the delivery of healthcare has kept growing over time and HR has become intrinsically important to the delivery of efficient and effective health care. At this point the organizations which have managed their human capital successfully and effectively have been able to serve their patients effectively(Kabene et al, 2006). In a scenario where the health care sector is faced with major human resource related issues the HR has a major opportunity to become a