Raft Accreditation Audit Case Study Task I

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Executive Summary of Accreditation Audit
June 2012

I prepared and reviewed an accreditation audit for Nightingale Community Hospital to organize and ensure compliance with Joint Commission standards for our hospital. We are preparing for a site visit that should occur within the next 13 months. I have reviewed the current compliance status of our hospital and will explain our corrective action plan that will ensure compliance with the Joint Commission standards for the focus area of communication.

An accreditation audit was performed by Carl Anderson, Director of Quality. We were only in 100% compliance in December throughout the year in one of the priority focus areas of the Joint Commission standard: Communication; Standard: …show more content…

This will be a double check off to insure safety. We will start a chart audit at projected start date July 1, 2012 and review in 90 days. The checklists will assure that all verifications and site identifications have been carried out.

A focused audit will be done on all patients undergoing operative or invasive procedures for the next year. Results will be analyzed by the nurse manager and discussed at staff meetings. Evaluation of compliance will be done at the staff meetings and any recommendations for improvement will be discussed and approved at these meetings. Implementation of any recommendations will be instituted the following month. Summaries of the audit and any recommendations for improvement will be sent to the PI committee on a quarterly basis.
A PI Coordinator will review all findings at staff meetings, department meetings, medical staff meeting and monthly at the PI Committee meeting. A summary of findings is presented to the governing board on a quarterly basis.

(Commission, 2012) Standard UP.01.02.01 Mark the procedure site. Mark the procedure site before the procedure is performed and, if possible, with the patient and or family involved. The procedure site is marked by a licensed independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed.
(Commission, 2012) The elements of performance state:


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