Accreditation Audit Task 1
Accreditation Audit
AFT Task 1
Lisa R. Green
A. Compliance Status
Nightingale Community Hospital (NCH) recently implemented processes to meet standards put forth by the Joint Commission to meet and exceed in five primary focus areas. (The Joint Commission.org) The primary focus area that NCH will highlight and potentiate will be in the area of communication. NCH is committed to the core values of safety, accountability, teamwork, and community. These core values cannot be met without clear and effective communication. NCH is anticipating an accreditation audit from The Joint Commission within the next thirteen months and we want to be prepared to excel. NCH wants to demonstrate to The Joint Commission that we provide and participate in very efficient communication with and about our patients and their healthcare from admission to discharge and everywhere in between. We need to support our commitment to our own core values by setting forth a corrective action plan based on The Joint Commission’s last audit findings and demonstrate not only a willingness to change, but the ability to improve on and maximize the importance of the primary focus area of communication. The Joint Commision Standards involved in the primary focus area of communication are UP.01.01.01 – Conduct a pre-procedure verification, UP.01.02.01 – Mark the procedure site, and UP.01.03.01- A time – out is performed before the procedure. To do this, a corrective action plan including four areas of focus has been established. The four focus areas of the corrective action plan are as follows: 1. Action Steps, 2. Accountable Parties, 3. Timeframe, and 4. Measurement.
A1. Plan for Compliance
Action Steps
Accountable Parties
Timeframe
Measurement
Conduct a preprocedure verification.
Registration personnel
Admission personnel
Floor personnel
Pre-operative personnel
Operative personnel
Post-operative personnel
Upon admission
Pre-operative area prior to procedure
Operative area at start of
AFT Task 1
Lisa R. Green
A. Compliance Status
Nightingale Community Hospital (NCH) recently implemented processes to meet standards put forth by the Joint Commission to meet and exceed in five primary focus areas. (The Joint Commission.org) The primary focus area that NCH will highlight and potentiate will be in the area of communication. NCH is committed to the core values of safety, accountability, teamwork, and community. These core values cannot be met without clear and effective communication. NCH is anticipating an accreditation audit from The Joint Commission within the next thirteen months and we want to be prepared to excel. NCH wants to demonstrate to The Joint Commission that we provide and participate in very efficient communication with and about our patients and their healthcare from admission to discharge and everywhere in between. We need to support our commitment to our own core values by setting forth a corrective action plan based on The Joint Commission’s last audit findings and demonstrate not only a willingness to change, but the ability to improve on and maximize the importance of the primary focus area of communication. The Joint Commision Standards involved in the primary focus area of communication are UP.01.01.01 – Conduct a pre-procedure verification, UP.01.02.01 – Mark the procedure site, and UP.01.03.01- A time – out is performed before the procedure. To do this, a corrective action plan including four areas of focus has been established. The four focus areas of the corrective action plan are as follows: 1. Action Steps, 2. Accountable Parties, 3. Timeframe, and 4. Measurement.
A1. Plan for Compliance
Action Steps
Accountable Parties
Timeframe
Measurement
Conduct a preprocedure verification.
Registration personnel
Admission personnel
Floor personnel
Pre-operative personnel
Operative personnel
Post-operative personnel
Upon admission
Pre-operative area prior to procedure
Operative area at start of