Joint Commission Accreditation Audit Preparation

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Joint Commission Accreditation Audit Preparation
Compliance Status for “Communication” Priority Focus Area Executive Summary
In preparation for the next Joint Commission Accreditation Audit, Nightingale Community Hospital is assessing the compliance status of each of the Joint Commission’s Priority Focus Areas (PFAs). This Assessment covers the “Communication” Joint Commission PFA. For the previous Joint Commission audit, there were no findings associated with this standard. Since The Hospital has recently undergone a great deal of staff turnover in the Standards and Communication Department, several of the Hospital Directors felt that this may be an area that has slipped in relation to compliance with this PFA. The Communication PFA is comprised of three general standards: •UP.01.01.01 Conduct a pre-procedure verification process. •UP.01.02.01 Mark the procedure site.

UP.01.03.01 A time-out is performed before the procedure. Each of these standards has elements of performance that Nightingale Community Hospital should be implementing through policies, protocols and checklists. Compliance with the performance elements s summarized in a compliance matrix. The matrix identifies the standard, the performance elements of the standard, and how the performance element is implemented. This matrix is an effective tool to assess where compliance gaps exist and it forms the basis for developing corrective action plans. The compliance matrix for the Communication standard in included at the end of this summary. Nightingale Community Hospital is implementing most of the performance standards. There is no documented implementation for the following performance elements. •Labeled diagnostic and radiology test results (for example, radiology images and scans, or pathology and biopsy reports) that are properly displayed (UP.01.01.01) •When two or more procedures are being performed on the same patient, and the person performing the procedure changes,...
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