Essay on Raft Task 1 Accredidation Auditing

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:

In accordance with this the hospital makes sure we follow guidelines laid down by Joint commission Standards. The compliance includes four areas…Information management, Infection control, Communication and Medication Management. The Goal here is patient safety and providing patients with safe and effective care of the highest quality and value.

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.

Nightingale Community Hospital (NCH), like many other health care facilities, uses a Periodic Performance Review (PPR) as an assessment tool that assists in examining performance on a consistent basis to ensure compliance with Joint Commission standards. A PPR concentrates attention on procedures, methods, and processes that contribute an environment that provides for proper care and emphasizes patient safety. NCH has shown to be 100% compliant with the majority of standards including: Infection Prevention and Control, Right and Responsibilities to Patients, Human Resources, Transplant

It was found that the nurses had insufficient recording of wound care and the staff were not monitoring the wounds consistently or keeping Mr Selir’s GP up to date on his condition. After this incident, the nursing home introduced new staff, systems and processes to improve the quality of care to residents. I felt frustrated and disturbed as coming from overseas, my family background has always taught us to respect and look after our elderly therefore back in our country we don’t believe in nursing homes. According to Nursing and Midwifery Board of Australia [NMBA] 2016, health professionals ought to provide safe, appropriate and responsive quality nursing practice.

A.Nightingale Community Hospital is attempting to be in complete compliance with Joint Commission’s “communications” standards. Prior to the Joint Commission survey, Nightingale Community Hospital wanted to focus on items UP.01.01.01 through UP.01.03.01 of the Joint Commission handbook. According to the handbook, these items focus on the universal protocols for preventing wrong site, wrong procedure, wrong person surgery (2015). In response to these universal protocols, the hospital implemented a pre-procedure hand-off tool, which is completed and signed off by both the nurse handing off the patient as well as the nurse accepting the patient. The hospital also began

Abbreviations as part of the communication plan; currently Nightingale Community evaluates the non-approved abbreviations monthly and has made improvements during the accreditation audit period. Non

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

This policy applies to all direct and indirect patient care processes, departments, and facilities of ABC Medical Center (ABC).

Nightingale Community Hospital (NCH) has thirteen months until their next Joint Commission audit. This report will evaluate Nightingale Hospital’s compliance in The Priority Focus Area of Communication using the Universal Protocol Standards from the Joint Commission Handbook. “The Universal Protocol was created to address the continuing occurrence of wrong site, wrong procedure and wrong person surgery and other procedures in Joint Commission accredited organizations” (Joint Commission, 2013).

In 2003, The Joint Commission made one of their first goals to improve the accuracy of identifying patients to reduce or eliminate patient identification errors. This continues to be an accreditation requirement. Their recommendations to do this are to use at least two patient identifiers when administering medications, and when providing treatments or procedures. Acceptable identifiers may be the individual’s name, an assigned identification number, telephone number, or other person-specific identifier. Patient room number or physical location may not be used as an appropriate identifier. Healthcare provides should re-identify the patient with each encounter, each medication pass, and each procedure. There have been procedures and protocols throughout the country have been put into place to make the care provided to patients safer. Another element of this requirement is that all containers should be labeled in the patients presences after using the patient identifiers

The scrub and scout nurse are responsible for the management of all items used during the procedure (ACORN 2014-15, p. 94). The initial count should be performed before the surgery starts and that establishes a baseline for the subsequent counts (D’Lima, et al 2014). All items should be completely separated, counted audibly and viewed during the count and documented on the count sheet accurately by the scout nurse. A

This pathway gives staff structure, support and professional integrity. Additionally, The Royal College of nursing, SCIE, and primary care trusts are all involved in the development of protocols and guidelines. This does however indicate that no service users are involved in the creation process, possibly resulting in service and organisational focused guidelines. Successfully implementing protocols has its barriers. The Open University, (K101 Introduction to Health and Social Care, Resources, 2014) highlights several problematic factors including, limited resources, staff shortages and equipment and medical supply problems. However, once implemented successfully these policies may help to manage risk, control budgets and reduce litigation.

“The Process Improvement in Stanford Hospital’s Operating Room” case has many issues when it comes to regards to its existing instrument provisioning process taking place within the Operating Room (OR) of Stanford’s Hospital. This process entails getting instruments ready for a surgery in the OR and the cleansing of these instruments afterwards; however, there are many problems that arise in this process.

Using computer the Cadence software program the surgical associate (SA) checks the patient in at the surgical registration desk (Barton,2015). This associate acknowledges the patient signature on the forms received at the general registration desk. The SA then prints and places an armband on the patient, after the patient verifies information, number on the armband. To complete this step the associate need the patient’s birth date, allergy information and the medical record number. The AA calls the designated procedural area to inform the nurse of the patients arrival.