Accreditation Audit

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

Care delivery models are an integral component for delivering patient care. With the collaboration of other members of the healthcare team, the Registered nurse is able to fully optimize his/her skill sets to provide to best quality care. As discussed consistency and coordinated care are the key. Studies must be conducted and evidence base practice must be implemented in order to find the model that is suitable for a particular unit. How models are implemented in an organization can be highly variable. Completion of this assignment has enlightened me on the profound impact that care models have in the flow of a unit. Newer models

Using the Patients Rights listed above the American Hospital Association identified what expectations patients have that should be met under the Patient’s Bill of Rights in the Patient Care Partnership. Patients should expect high

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

The purpose of this report is to summarize, analyze and evaluate the compliance status of Nightingale Hospital to Joint Commission requirements. This report will focus on medication management, specifically anticoagulation therapy and the patient and staff education associated with it. In an effort to maintain the highest quality of care for our patients, we must continue to work towards a reduction in adverse anticoagulation related events. This will involve proper pre-discharge

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.

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

5. The Patient Safety Officer will train the risk assessment team members on the proactive risk assessment process and how to conduct a proactive risk assessment, including the assessment of risk, itself.

The CNO outlined professional standards for nurses to comply with. The seven that are outlined are accountability, continuing competence, ethics, knowledge, knowledge application, leadership, and relationships. “A standard is an authoritative statement that sets out the legal and professional basis of nursing practice” (College of Nurses of Ontario, 2009, p. 3). Although each standard has different meaning, they all work together in order to provide the best possible patient care.

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).

Nurses use a systematic approach to providing individualized care to meet health care needs of patients, families, populations and communities without prejudice. Because nurses assume the responsibility and accountability of all patient care it is critical that they are professional and competent. Setting goals plays a massive part in the guidelines for the nursing practice. This prevents nurses from getting overwhelmed and overloaded. They need time to deliberate and make changes accordingly in order to constantly improve the quality of care for each and every patient. When conflict does arise the cooperation of key players can be beneficial to help improve a situation or problem. Writing a journal and setting goals makes it much easier for nurses to recognize what areas they need a little reinforcing.

We should raise concerns with appropriate people or management about practice and policies if necessary,