Preparing for The Joint Commission, Nightingale Community Hospital reviews areas of compliance and non-compliance. A periodic performance review, which is a self-evaluation, is utilized by Nightingale Community Hospital, to prepare for The Joint Commission. The Joint Commission has eighteen accreditation requirements. (Commission, 2013) The periodic performance review found the hospital to be compliant and non- compliant in the following areas:
Compliant: Emergency Management Human resources Infection Prevention and Control Performance Improvement Right and Responsibilities of the Individuals Transplant Safety Waived Testing
Non- Compliant Environment of Care Leadership Life Safety Medication Management Medical Staff National Patient Safety Goals Nursing Provision of Care, Treatment, and Services Record of Care, Treatment, and Services
The hospital has been found to have increase clutter in the hallways, which is a fire hazard and is a safety issue. Nurses were found to be unfamiliar with proper verbal order procedures, how to use the range of orders received and what abbreviations that are prohibited within documentation. The trend shows areas that the hospital needs to implement audits, and education. An action plan will be devised that meets the needs of each unit and areas of non-compliance with proper follow up. In order to be the hospital of choice, administration needs to implement an action plan to address the fallouts. By reviewing non-compliant areas the hospital can assess how to prevent fallouts. Understanding the importance and benefits of The Joint Commission requirements provides the hospital with standards. These standards continue to help the hospital provide the best care.
A2. Non-compliant Trends -
Utilizing the periodic performance review to the fullest allows the hospital to examine areas of non-compliance in comparison to The Joint Commission standards. The hospital found non-
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