Accreditation Audit Task 1.
Communication, this is the key focus area that is evaluated in this summary. Communication is a key focus area of the joint commission audit and is also a key area in which Nightingale Community can make enhancements. Communications must be a two way free flow of information. The information exchanges occur between providers, staff, and patients or clients. This was an area that needed improvement was noted in the previous accreditation audit. Some noted prior issues from 2 years ago included patient and family education and information not being properly disseminated to the nursing staff. These are areas where we have targeted and currently meet. Some areas that we continue to work on are as follows. We currently need to address our time out policy. During the last year there were three months that Nightingale Community did poorly in this area. We must make sure that the time outs are not only conducted properly but more importantly documented in the patients chart. If the time out is not properly documented in the patients chart the organization will not receive credit, it will be as though it never occurred. We must make sure that all providers and clinical staff have appropriate training and training materials provided for the time out policy. We will continue to quantify our efforts monthly in this key area. We as an organization must make this goal monthly. Critical results are an issue of concern for the organization. Critical results must be reported within 60 minutes and this must be documented. This is an area like the time out policy where if it is not in the patient’s record it did not occur. We must strive to improve our documentation to support that our critical results have been reported timely. We will both improve documentation and we will continue to audit our documentation to assure compliance. Our monthly goal will be to properly document 80% or better of critical outcomes. The site I.D. policy is our third...
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