Accredidation Audit

Topics: Nursing, Medicine, Patient Pages: 9 (2331 words) Published: February 23, 2014

Accreditation Audit-AFT Task 4
Western Governors University

Discuss the current compliance status of the healthcare facility.

Nightingale Community Hospital (NCH); a 180-bed, acute care, not for profit organization provides services in critical and emergency care, Oncology, cardiology, general medical and surgical services and neuroscience, vascular, level II nursery units amongst a few others. Providing these services Nightingale has held a commitment of safety, community, teamwork, and accountability. These four values have kept Nightingale compliant in several accreditation functions required by the Joint Commission. Audits, interviews, observance and chart reviews; the Director of Accreditation has found that NCH has met accreditation standards in performance improvements (PI), rights and responsibilities of the individual (RI), transplant safety (TS), emergency management (EM), infection control (IC), and human resource (HR). Looking to the upcoming accreditation audit NCH has created effective plans in emergency operations, prevention and control, qualifications set for the hospital and staff, adequate data collection, in-depth attention to organ and tissue donation and procurement and patient rights; NCH is ready for audit in theses areas. Discuss any trends evident in that may cause the organization to not be compliant with the Joint Commission standards for patient care.

Although, several areas have reached a level of compliance at NCH; others need review to be in compliant and ready for audit. NCH is not compliant within the accreditation functions of the following: Life Safety (LS), Record of Care (RC), Information Management (IM), Universal Protocol (UP), Medication Management (MM), Environment of Care (EC), Provision of Care, Treatment and Services (PC), National Patient Safety Goals (NPSG), Nursing (NR), Leadership (LD), and Medical Staff (MS). Joint Commission standards LS.03.01.20 and EC.02.03.03 “requires exits, exit accesses, and exit discharges are clear of obstructions or impediments to the public way, such as clutter and the hospital conducts fire drills once per shift per quarter in each building defined as a health care occupancy”. Upon review of the fire drill reports and observance during PPR rounds it was discovered that the fire drill process is inconsistent and did not meet JC standards and clutter was found on multiple floors such as OR and Telemetry. RC.02.03.07 is a standard that is seen throughout Nightingale as an area of non compliance but with an average of 81.25% of verbal orders actually being authenticated within 48 hours this issue can be corrected with an effective implementation plan. The hospital is to follow a list of prohibited abbreviations, acronyms, symbols, and dose designations; by using those prohibited abbreviations in progress, nursing, and physician orders/notes in units 3E, 4E, ICU, and Telemetry Nightingale is out of compliance hospital wide in regard to the IM.02.02.01 standard. Nursing (NR) and Leadership (LD) functions require that “nurse executives routinely assume oversight responsibility for the provision of safe, effective, high-quality nursing care throughout the hospital; development, presentation, and management of the nursing services’ portion of the hospital’s budget; work team productivity; consumer satisfaction activities; and staff retention efforts (NR.02.02.01)” and its “leaders provide for the effective functioning of the hospital with a focus on safety and quality (LD.03.06.01).” Nursing staff on 3E have forgotten the valued culture of quality care, safety, and service. This attitude could possibly have contributed to other areas not meeting compliance on 3E? NGH must review medication policies before audit. Medication management falls out of compliance because nursing staff are not educated on range order policies and therefore are not consistently...
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