Acceditation Audit AFT Task 4
Accreditation Audit AFT Task 4.
A1. Compliance Status
The ongoing survey readiness audits that are conducted in the hospital on a daily basis have identified areas we will focus on to ensure that our accreditation survey results are exceptional. Audits are performed on an ongoing basis with a focus on trends that are most commonly cited by the Joint Commission. Nightingale hospital has proven to have made great improvements over prior survey findings in Emergency Management, Human Resources, Leadership, Medical Staff, Nursing Care, Provision of Care, Treatment and Services, Information Management, Handoff Communication and critical value reporting. We have placed an abundance of resources and efforts into improvement in these categories and will continue to make strides to further improve every aspect of the care we provide to our patients. (The Joint Commission, 2013)
A2. Noncompliant Trends
The areas we have identified that are not in compliance with the Joint Commission standards are:
1) Environment of care findings with numerous smoke wall penetrations, interim life safely measures for construction projects, blocked fire extinguishers, lack of sufficient evidence of adequate fire drills, lack of testing for medical gas alarm panels, blocked sprinkler clearance as well as cluttered hallways.
2) Falls has continue to be a challenge for our organization and will continue to be a focus for every department in our hospital.
3) Moderate sedation is an area that has been identified that needs a hardwired process for not only the hospital but for the anesthesia providers. The Joint Commission standards for moderate sedation compliance will require teamwork from the hospital and anesthesia group.
4) Pain assessment and reassessment is an ongoing primary focus area that we have not mastered in our organization. We have developed performance improvement processes to work toward compliance. This standard is a focus for every inpatient and outpatient
A1. Compliance Status
The ongoing survey readiness audits that are conducted in the hospital on a daily basis have identified areas we will focus on to ensure that our accreditation survey results are exceptional. Audits are performed on an ongoing basis with a focus on trends that are most commonly cited by the Joint Commission. Nightingale hospital has proven to have made great improvements over prior survey findings in Emergency Management, Human Resources, Leadership, Medical Staff, Nursing Care, Provision of Care, Treatment and Services, Information Management, Handoff Communication and critical value reporting. We have placed an abundance of resources and efforts into improvement in these categories and will continue to make strides to further improve every aspect of the care we provide to our patients. (The Joint Commission, 2013)
A2. Noncompliant Trends
The areas we have identified that are not in compliance with the Joint Commission standards are:
1) Environment of care findings with numerous smoke wall penetrations, interim life safely measures for construction projects, blocked fire extinguishers, lack of sufficient evidence of adequate fire drills, lack of testing for medical gas alarm panels, blocked sprinkler clearance as well as cluttered hallways.
2) Falls has continue to be a challenge for our organization and will continue to be a focus for every department in our hospital.
3) Moderate sedation is an area that has been identified that needs a hardwired process for not only the hospital but for the anesthesia providers. The Joint Commission standards for moderate sedation compliance will require teamwork from the hospital and anesthesia group.
4) Pain assessment and reassessment is an ongoing primary focus area that we have not mastered in our organization. We have developed performance improvement processes to work toward compliance. This standard is a focus for every inpatient and outpatient