Accreditation Audit

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Accreditation Audit RAFT Task 1

Executive Summary

Nightingale Community Hospital (NCH) is a hospital that states they are leaders in quality healthcare. To remain a leader in hospital care it is crucial for the hospital to adhere to standards developed by the Joint Commission Accreditation on Healthcare Organizations (JCAHO). JCAHO is the organization that accredits and certifies hospitals that meet certain performance standards nationally. Only those hospitals that have the JCAHO accreditation are ensured to be in compliance with specific guidelines in each Priority Focus Areas: Infection control, Communication, Medication Management, and Information Management. Here at Nightingale Community Hospital safety is our top core value and in recent evaluations done by JACHO it obvious that there is are some problematic areas in Communication preventing us to pass compliance standards with 100% marks. I will review current Communication policies and assess proposed changes that can be implemented to increase the future compliance standard percent.
Priority Focus Areas standards of Communication in each Element of Performance are as follows:
A.
UP.01.01.01: Conduct a pre-procedure verification process - The first Element of Performance within the PFA of the Communication policies within NCH requires the hospital to conduct a pre-procedure verification process to ensure that the correct procedures being performed will be done on the correct person and site. The current standard of conducting a pre-procedure verification process is written in the policy, however, on the Hand-off form there is no area to verify the patient, procedure or site, only if the site has been marked. In the second Element of Performance of this standard, NCH is not in compliance in communicating what equipment will be needed and identified with the patient and the procedure to be done. Again, the



References: Site identification and verification policy. (2012). Nightingale Community Hospital Mulloy, D.F., & Hughes, R.G., (1999) Wrong-site surgery: a preventable medical error, Chapter 36, retrieved from December 26, 2012 from http://www.ahrq.gov/qual/nurseshdbk/docs/MulloyD_WSS.pdf Universal communication protocol. In (2012). Nightingale Community Hospital

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