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
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.
Joint Commission. (2010). Management of Human Resources. CAMH: Comprehensive Accreditation Manual for Hospitals, Hr-1 - HR-10.
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 four main areas of focus for the Joint Commission for Nightingale Hospital include Communication, Information Management, Medication Management and Infection
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.
Nightingale Community Hospital has some adjustments to make to their current policy relating to the PFA of Communication to ensure that they are compliant with JCAHO’s standards. Suggested adjustments for each standard to meet JCAHO standards:
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.
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
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
Nightingale Community Hospital provides professional care that ensures total security and satisfaction to those who wish to benefit from our care.
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 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.
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)
1.The main roles and responsibilities of the employee in relation to prevention and control of infection are as follows:
Managers rely on HR to provide effective staff capable of accomplishing the goals of the organization. HR is valuable in ensuring