Wgu Accreditation Audit Aft2 Task 4 Essay

2774 Words12 Pages
Continuous Accreditation Compliance - Task 4 AFT2 Accreditation Audit October 31st, 2014 Continuous Accreditation Compliance - Task 4 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…show more content…
The Joint Commission (n.d.) states that, “Verbal orders are authenticated within the time frame specified by law and regulation”( Joint Commission, n.d., RC.02.03.07 - 4). With so many departments found to be in non-compliance during the process of just one audit this trend proves this issue is likely widespread throughout the entire hospital and that NCH is regularly non-compliant with this issue. The departments that did not show to have this non-complaint issue were: Cardiac Cath Lab, Endoscopy, ICU, OR, and Surgery Pre-op. To fix this issue, it is advisable to ascertain why and how some departments are meeting the standard while others are not. This issue may stem from improper procedures, training, a deficiency in staffing, or a lack of leadership in the non-compliant departments. Comparing and contrasting the departments should assist in resolving this non-compliant issue. Prohibited Abbreviations There are two prohibited abbreviations that are tracked, “cc” and “qd”, as they are the most common. Throughout the year there has not been consistent improvement in the area. The trending data shows some improvement in parts of the year and then some months, April and September, to have increased spikes of use of prohibited abbreviations. During the PPR it was noted that the following departments were non-compliant concerning using prohibited abbreviations: 3E, 4E, ICU, and Telemetry. The

    More about Wgu Accreditation Audit Aft2 Task 4 Essay

      Open Document