Periodic Performance Review

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RAFT Task 4

Nightingale Hospital is currently compliant with many standards of the Joint Commission. Nightingale has proven its compliance with the Emergency Management standard by providing plans on how it will respond in an emergency. They proved their compliance with the Human Resources standard by showing their commitment to the continuing education and training of their staff. The Infection Prevention and Control standard was met by Nightingale by presenting the procedures in place for effective infection prevention and control. The hospital met the Performance Improvement standard by showing that the performance of processes that support care were evaluated and the data from those evaluations were used to make improvements. Nightingale proved their compliance with the Rights and Responsibilities of the Individual standard by showing they recognized and respect patient rights. The Transplant Safety standard was met by providing documentation and proof of implementation of policies and procedures for safe organ and tissue donation, procurement, and transplantation. Finally, the Waived Testing standard was met by Nightingale by presenting policies and procedures relating to the use of test results done by patients. There are many standards in which Nightingale is not compliant. For the Environment of Care standard, the hospital was unable to show it provided a safe, functional hospital environment. Nightingale’s issue with adequate staff prevented them from qualifying for the Leadership standard. Fire safety prevented approval for the Life Safety Standard for Nightingale. When it comes to the Medication Management standard, the hospital was unable to show correct medication processes. For the Medical Staff standard, interviews with staff showed OPPE process did not meet standards. Issues with labeling prevented approval for the National Patient Safety Goals standard. Consistent failure to document prevented the Nursing standard from being met. The...
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