Accreditation Audit Task 4

Topics: Hospital, Nursing, Patient Pages: 7 (2223 words) Published: July 16, 2012

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.

Rather than focus on the discrepancies found within each unit, we will look at the trends that affect the hospital’s compliance with the Joint Commissions recommendations regarding patient care. Armed with the trends, we will then explore staffing patterns and how they relate to patient care in order to establish a plan that will assist our hospital to minimize patient safety issues as they relate to falls, pressure ulcers, pneumonia, and the general safety of our patients.


Although the Joint Commission standards clearly define the requirements for an organization to remain in compliance with the patient care and safety criterion for accreditation, Nightingale Community Hospital’s policies are not being routinely followed throughout each unit. The policy that states verbal orders must be authenticated within 48 hours is not being followed in several units and there seems to be little, if any consistency throughout the hospital with regards to policy observations. Generally, the compliance rate in the second quarter was steady and the best of all quarters, while the third quarter compliance results were very poor. Policy must be reviewed and standards improved in order to bring the hospital into compliance. Policy that should be implemented include a form in which the nurse who takes the order must sign and date the form and place it on outside of the patients chart to alert the physician that actions are required of him regarding this patient.

Only two abbreviations were monitored in ICU, Telemetry, 3E, and 4E because they are the most frequently used forbidden abbreviations. These forbidden abbreviations are “cc” and “qd”. The audit revealed “cc” was most often used in the months of April and September. The abbreviation “qd” was used much more sparingly but was used most often during the months of June and July. The second and third quarters proved to be the quarters when the two prohibited abbreviations were used the most. To increase awareness of prohibited abbreviations, a list will be posted in the nursing station in close proximity to where the charting takes place. Nurses and nursing staff will receive education regarding the use of approved abbreviations as set forth by the Joint Commission. Additionally, everyone who documents in the patients chart will be required to sign and date the entry at the time of documentation.

The pain assessment audit was another standard that was out of compliance with the Joint Commission recommendations. The ED, 3E, and PACU were the units focused on for this portion of the audit. Clearly, the Emergency Department was the least compliant throughout the year for pain assessment. This may be due to the urgency or life threatening events in which pain assessment is not a priority. Regardless of the reason for neglecting to assess for pain, it is a requirement for accreditation. Each assessment should be documented in the patient’s record of care and all personnel responsible for patient care must receive education regarding the necessity of the pain assessment. The Nurse Managers of each department has the responsibility of implementing a corrective action plan based on the particular department standard of care.

The Joint Commission’s focus is on safety. At Nightingale Community...

Cited: Dall, T. C. (2009). The Economic Value of Professional Nursing. Medical Care, 97-104.
Joint Commission. (2010). Management of Human Resources. CAMH: Comprehensive Accreditation Manual for Hospitals, Hr-1 - HR-10.
Stanton, M. R. (2004, March). Hospital Nurse Staffing and Quality of Care. Research in Action. Rockville, MD, USA: Agency for Healthcare Research and Quality.
(2005). Utilization guide for the ANA principles for nurse staffing. Washington, DC: American Nurses Association.
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