Accreditation Audit Task 4
COMPLAINCE STATUS
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.
NON-COMPLIANT TRENDS
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 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.
NON-COMPLIANT TRENDS
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
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.