WGU Accreditation Audit: RAFT Task 1 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”
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Executive Summary 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. Areas that require further documentation will be on the following Elements of Performance: A. Compliance Status UP.01
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Accreditation Audit AFT Task 1 Lisa R. Green A. Compliance Status Nightingale Community Hospital (NCH) recently implemented processes to meet standards put forth by the Joint Commission to meet and exceed in five primary focus areas. (The Joint Commission.org) The primary focus area that NCH will highlight and potentiate will be in the area of communication. NCH is committed to the core values of safety‚ accountability‚ teamwork‚ and community. These core values cannot be met without clear
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1. Compliance Status 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. Hospitals are one of the many organizations that must comply with regulations to keep patients and staff safe and as well as maintain the quality of care. Ideally‚ a good care system for patients includes
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Preoperative/Preprocedure Verification Process is addressed. There is also a Preprocedure Hand-Off form present. This form is a bit misleading as it is essentially a hand-off form in general with a few extra boxes possible for check-off. To prepare for inspection and audit‚ NCH should create and implement a form for use within the Operating Theater or wherever procedures are performed‚ such as bedside procedures. This form needs to be more specific in addressing at least the minimum requirements by JC. The form needs
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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
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Accreditation Audit AFT Task 3 Lisa R. Green A1. Evaluation Nightingale Community Hospital (NCH) is committed to upholding the core values of safety‚ accountability‚ teamwork‚ and community. In preparation for the upcoming readiness audit‚ NCH will be launching a corrective action plan in direct response to the recent findings in the tracer patient. Background information on the tracer patient is as follows: 67 year old female postoperative patient recovering from a planned laparoscopic
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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
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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
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RAFT Task 1 Executive Summary By Cindy Granger December 1‚ 2011 Mission: To implement a corrective action plan in the area of Communication for Nightingale Community Hospital as required for Joint Commission Compliance. Corrective Action Plan: Standard: UP.01.01.01: Conduct a Preoperative Verification Process. At the present time Nightingale Community Hospital is not in compliance with rule UP.01.01.01. Nightingale currently has a five step verification process in regards to Preoperative/Pre-procedure
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