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Accreditation Audit Essay

1729 words - 7 pages

Joint Commission is dedicated to ensuring the continuous improvement with regulatory compliance. Accreditation offers reassurance to patients, staff and visitors that the healthcare facility has met and exceeded standards in providing quality care. Nightingale Community Hospital, utilized a periodic performance review to prepare for Joint Commission. This self-evaluation pointed out the following areas that were compliant;
Emergency management-Nightingale Community Hospital provides safe and effective patient care environment during an emergency. They evidently define and train their staffs’ roles and responsibilities through departmental communication. Joint Commission requires ...view middle of the document...

Human resources-Nightingale has been able to provide competent and sufficient number of staff based on the hospitals’ level of need. They continue to provide training for nursing personnel on specific work-related issues.
And transplant safety- Joint Commission requires hospitals to develop and implement policies and procedures for the donation and procurement of organs and tissues. Nightingale has made a commitment to providing the best in leadership in quality health services in regards to the maintenance of all records of potential organ, tissue, or eye donors sent to organ procurement.
And those that were non-compliant; environment of care standard requires hospitals to provide a safe and functional environment for patients, staff and visitors by preventing accidents and injuries; these factors include fire protection systems, i.e smoke detectors, fire extinguishers and emergency evacuation plans; during the PPR the hospital had an increase of hallway obstructions “clutter/carts in the hallway There were mobile carts, stretchers and even linen carts placed in front of fire extinguishers, which would be a safety concern in the event of a fire.
Leadership- this specific standard addresses documentation and timeliness, upon review there appears to be inconsistencies from all units within the hospital,
Information Management - this standard comprises of written policies regarding the privacy, security and integrity of health information of the patient. Prohibited abbreviations were found in nursing note and physician orders in the chart review during PPR.
Medication management- an important component in treatment of diseases, hospitals need to develop an effective and safe medication system. In staff interviews it was found that nurses are unsure of range order policy and how it should be executed. Quite a few medical instruments such as syringes were found unlabeled in the OR and Cath Lab.
Universal protocol- Hospitals are required to develop guidelines for the implementation of universal protocol for the prevention of wrong site, wrong procedure and wrong person surgery. Within the assessment of Nightingale there were several sentinel events that failed to comply with the standard. An unmarked lung biopsy and a knee arthroscopy site that was unmarked were a few liable events that could have been
National patient safety goals-This standard promotes and enforces major changes in patient safety for thousands across the world. For determining its’ value, the impact, cost and effectiveness are taken in consideration. Upon observation during the PPR there were unlabeled basins and pre-labeled syringes,
Record of care-this standard refers to the intake and release information once a patient enters the hospital. There was a deficiency noted in verbal order not being authenticated within 48 hours, this appears to be provision of care and medical staffing.
In order to be the hospital of choice, Nightingale will need to...

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