Executive Summary for Joint Commission
June 21, 2012
RAFT Task 1
Executive Summary for Joint Commission Standards Compliance
Nightingale Community Hospital provides leadership in quality health services. We also provide compassionate and cost-effective service in the lines of treatment and prevention.
Our vision is to be the hospital of choice for patients, employees, physicians, volunteers, and the community.
In accordance with this the hospital makes sure we follow guidelines laid down by Joint commission Standards. The compliance includes four areas…Information management, Infection control, Communication and Medication Management. The Goal here is patient safety and providing patients with safe and effective care of the highest quality and value.
I have chosen the priority focus area of Communication to discuss the current compliance standard of our hospital. The focus will be on the standards which failed to meet a 100% compliance with the Joint commission Accreditation.
1. Hospital-Wide Compliance of Reporting Critical results within 60 Minutes:
Reporting in a timely fashion as defined in the compliance standards reduces complications and critical outcomes. Or goal s 100% but our performance has ranged from 56% to 75% from January to June and has shown a subtle increase from 57% to 82% in the latter half of the year average. The reasons for delayed reporting were identified: · Lack of education in staff members regarding critical values and critical tests. · Lack of personnel in delivering the samples to the lab. · Delay in communication between staff and Physician either due to unavailability of the physicians after hours contact information or lack of communication. · Laboratory-based policies directed laboratory staff that critical values are telephoned immediately upon verification of accuracy but no explicit time frames were set if unable to reach care provider. · Lack of a common shared policy for uniform communication of all types of test results to all
RAFT Task 1
Executive Summary for Joint Commission Standards Compliance
Nightingale Community Hospital provides leadership in quality health services. We also provide compassionate and cost-effective service in the lines of treatment and prevention.
Our vision is to be the hospital of choice for patients, employees, physicians, volunteers, and the community.
In accordance with this the hospital makes sure we follow guidelines laid down by Joint commission Standards. The compliance includes four areas…Information management, Infection control, Communication and Medication Management. The Goal here is patient safety and providing patients with safe and effective care of the highest quality and value.
I have chosen the priority focus area of Communication to discuss the current compliance standard of our hospital. The focus will be on the standards which failed to meet a 100% compliance with the Joint commission Accreditation.
1. Hospital-Wide Compliance of Reporting Critical results within 60 Minutes:
Reporting in a timely fashion as defined in the compliance standards reduces complications and critical outcomes. Or goal s 100% but our performance has ranged from 56% to 75% from January to June and has shown a subtle increase from 57% to 82% in the latter half of the year average. The reasons for delayed reporting were identified: · Lack of education in staff members regarding critical values and critical tests. · Lack of personnel in delivering the samples to the lab. · Delay in communication between staff and Physician either due to unavailability of the physicians after hours contact information or lack of communication. · Laboratory-based policies directed laboratory staff that critical values are telephoned immediately upon verification of accuracy but no explicit time frames were set if unable to reach care provider. · Lack of a common shared policy for uniform communication of all types of test results to all