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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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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and regulations (Compliance and Regulatory Compliance‚ 2013)”. For this reason there are terms of compliance that hospitals must adhere to. The Joint Commission Handbook serves as a means of regulation and compliance for hospitals and other such facilities. There are four categories that the Joint Commission focuses on during the accreditation audits for a hospital: Information Management which involves the efficient management of health information and accuracy‚ Medication Management involving labeling
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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
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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
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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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Joint Commission Accreditation Audit Preparation Compliance Status for “Communication” Priority Focus Area Executive Summary In preparation for the next Joint Commission Accreditation Audit‚ Nightingale Community Hospital is assessing the compliance status of each of the Joint Commission’s Priority Focus Areas (PFAs). This Assessment covers the “Communication” Joint Commission PFA. For the previous Joint Commission audit‚ there were no findings associated with this standard. Since The Hospital
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Joint Commission (JC) standards. Standard: UP.01.01.01: Conduct a preprocedure verification process. Nightingale Community Hospital has a Site Identification and Verification policy and procedure. Within this policy‚ and 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
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|SECTION: |EFFECTIVE DATE: October 1‚ 2006 | |SUBJECT: |PAGE 1 of 8 | |Proactive Risk Assessment Policy | | Scope: This policy applies to all direct and indirect
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