Accreditation Audit Task 4

Better Essays
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
…show more content…
3E-Oncology had a previous average of 5.57 falls per 1000 patient days; average falls with injury per 1000 patient days was 0.89, with nosocomial pressure ulcer rate of 2.76%. Conducting root cause analysis revealed there were no direct trends related to the clinical indicators and the human resource indicators (nursing care hours and overtime). With no evident trending reports and realizing that these numbers still exceeded linear measurements; 3E took a vase approach to decreases these numbers by focusing on additional training and

You May Also Find These Documents Helpful

  • Better Essays

    Accreditation Audit Task 4

    • 2223 Words
    • 7 Pages

    The Joint Commission defines the Periodic Performance Review as an assessment tool created to assist health organizations improve and monitor their performance throughout the year. This tool focuses on the processes that influence patient care and safety while providing the structure for unremitting standards fulfillment. Nightingale Community Hospital is compliant with most standards as set forth by the Joint Commission. However, upon inspection and in an effort to stay focused on compliance, our standards committee has located a few discrepancies that must be resolved to maintain our accreditation with the Joint Commission.…

    • 2223 Words
    • 7 Pages
    Better Essays
  • Powerful Essays

    Accreditation Audit Task 1

    • 1716 Words
    • 6 Pages

    Following rules and regulations is important for institutions and any type of establishment to maintain organization and most importantly provide safety for those involved. For the organization and safety of everyone involved, it is important to comply with particular criteria.…

    • 1716 Words
    • 6 Pages
    Powerful Essays
  • Good Essays

    With all of the possible problems that could occur during surgery, a wrong-site, wrong-patient mistake is one that should never arise. Nightingale Community Hospital (NCH) fully understands the importance of doing away with these errors and has set up protocol to work towards this goal. While the protocol is in place, it is not fully compliant with Joint Commission (JC) standards.…

    • 791 Words
    • 3 Pages
    Good Essays
  • Better Essays

    Nightingale Community Hospital (NCH) has thirteen months until their next Joint Commission audit. This report will evaluate Nightingale Hospital’s compliance in The Priority Focus Area of Communication using the Universal Protocol Standards from the Joint Commission Handbook. “The Universal Protocol was created to address the continuing occurrence of wrong site, wrong procedure and wrong person surgery and other procedures in Joint Commission accredited organizations” (Joint Commission, 2013).…

    • 1465 Words
    • 6 Pages
    Better Essays
  • Good Essays

    Even though Nightingale Hospital has a very detailed Site Identification and Verification Protocol, some areas do not meet JHACO’s standards. Updating the Universal Protocol and Preprocedure Hand-Off Check sheet will not only bring the facility into compliance but may eliminate any potential failure in communication between patient, caregiver and provider.…

    • 740 Words
    • 3 Pages
    Good Essays
  • Powerful Essays

    AFT Task 1

    • 1255 Words
    • 5 Pages

    A readiness review was conducted of Nightingale Hospital’s Universal Protocol in preparation for a Joint Commission audit. The Joint Commission standards that were a part of this review consist of: UP.01.01.01; Conduct a pre-procedure verification process, UP.01.02.01; Mark the procedure site, and UP.01.03.01; A time-out is performed before the procedure. Nightingale Community Hospital documentation identified for this review is as follows:…

    • 1255 Words
    • 5 Pages
    Powerful Essays
  • Better Essays

    Quality of nursing home care is a major deciding factor for recovering from illness or injury. Mecklenburg Health & Rehabilitation Center is for-profit corporation, which participates in Medicare and Medicaid programs. It consist of 100 beds and is located on Southwest part of Charlotte, North Carolina. Although, it is not a hospital…

    • 1042 Words
    • 5 Pages
    Better Essays
  • Good Essays

    Nightingale Community Hospital provides leadership in quality health services. We also provide compassionate and cost-effective service in the lines of treatment and prevention.…

    • 1778 Words
    • 8 Pages
    Good Essays
  • Better Essays

    The areas listed above as Priority Focus Areas for Nightingale Hospital have been evaluated using Internal Audit data. The following findings have been documented:…

    • 944 Words
    • 4 Pages
    Better Essays
  • Better Essays

    The Hospital Alliance Association (HospAA), (2010, April 5) Joint Commission on Accreditation of Healthcare Organization. Retrieved from http://hospaa.org/?p=347…

    • 2102 Words
    • 9 Pages
    Better Essays
  • Better Essays

    Fall Prevention Case Study

    • 3462 Words
    • 14 Pages

    The data was collected from the National database of Nursing Quality Indicators between the year 2006 and 2008. The patients were under observation for 88 million days and this data was taken from the Medical and the surgical units. A total of 315,817 falls were noticed during this study period. During the 27 month study, it was noted that the trend decreased to fewer falls.…

    • 3462 Words
    • 14 Pages
    Better Essays
  • Better Essays

    1) If reported sales for 2010 erroneously include sales that occur in 2011, the assertion violated on the 2010 statements would be:…

    • 3630 Words
    • 15 Pages
    Better Essays
  • Good Essays

    The Joint Commission medical staff standards defines evaluation standards, the commission pushes hospitals toward unbiased and evidence-based decisions in credentialing and privileging. In this scenario the rules and policies are clearly mapped out, yet they are not being properly followed. The verbal order audit results seem to have no consistency. These standards now outdate…

    • 813 Words
    • 4 Pages
    Good Essays
  • Satisfactory Essays

    5. All accounts payable owed as of the balance sheet date are included in the financial statements.…

    • 458 Words
    • 2 Pages
    Satisfactory Essays
  • Powerful Essays

    Nightingale Home Health Care Services is a new home health care agency that will offer a unique combination of premier home health care and community-based social services to the Bryn Mawr area in Philadelphia. Our office will be located will be established in quality office space on Main Street in Bryn Mawr, Pennsylvania and will provide the following services to clients and patient in that demographic.…

    • 1443 Words
    • 6 Pages
    Powerful Essays