Executive Summary
Executive Summary - Infection Control and Prevention Current Compliance Status for Joint Commission Accreditation
Nightingale Community Hospital is committed to providing healthcare excellence, a healing environment and to be the choice for patient care. In order to continue to provide quality healthcare services in accordance with our values of safety, community, teamwork, and accountability Joint Commission Accreditation provides guidelines and standards for the Priority Focus Areas (PFA) for the welfare and quality of patient care.
Infection control and prevention extends beyond treating the patient. It encompasses all who work and visit the facility including medical staff, administrative staff, volunteers, vendors, and visitors. Implementing activities and programs to control, treat, prevent and identify sources of infection will help ensure the overall satisfaction and quality of patient care. Based on previous fiscal year data Joint Commission has identified Infection Control as one of the PFAs. In order to be in compliance with the standards and guidelines of Joint Commission Accreditation five areas of Infection Control and Prevention have been identified:
1. The hospital implements its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection.
2. Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.
3. Implement evidence-based practices to prevent healthcare– associated infections due to multidrug-resistant organisms in acute care hospitals.
4. Implement evidence-based practices to prevent central line– associated bloodstream infections.
5. Implement evidence-based practices for preventing surgical site infections.
There are opportunities to implement and to improve on established programs for Infection Control and Prevention. Establishing and
Nightingale Community Hospital is committed to providing healthcare excellence, a healing environment and to be the choice for patient care. In order to continue to provide quality healthcare services in accordance with our values of safety, community, teamwork, and accountability Joint Commission Accreditation provides guidelines and standards for the Priority Focus Areas (PFA) for the welfare and quality of patient care.
Infection control and prevention extends beyond treating the patient. It encompasses all who work and visit the facility including medical staff, administrative staff, volunteers, vendors, and visitors. Implementing activities and programs to control, treat, prevent and identify sources of infection will help ensure the overall satisfaction and quality of patient care. Based on previous fiscal year data Joint Commission has identified Infection Control as one of the PFAs. In order to be in compliance with the standards and guidelines of Joint Commission Accreditation five areas of Infection Control and Prevention have been identified:
1. The hospital implements its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection.
2. Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.
3. Implement evidence-based practices to prevent healthcare– associated infections due to multidrug-resistant organisms in acute care hospitals.
4. Implement evidence-based practices to prevent central line– associated bloodstream infections.
5. Implement evidence-based practices for preventing surgical site infections.
There are opportunities to implement and to improve on established programs for Infection Control and Prevention. Establishing and