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Accreditation Audit Task 4 Essay

3108 words - 13 pages

Running head: ACCREDITATION AUDIT- TASK 4
COMPLAINCE STATUS
Joint Commission clearly explained that a Periodic Performance Review is as an assessment tool designed to help in assisting the healthcare organization contributes greatly in the improvement and monitoring performance all through the year. The periodic performance focuses more on the measures that has to do with patients safety and care and at same time given the facility for unremitting standards fulfillment. NCH is 100% compliance with most standards of Joint Commission in the following area; Emergency Management, Human resources, Infection Prevention and Control, Performance Improvement, Right and Responsibilities of the ...view middle of the document...

One of the major steps to take is to explore the patterns of the staffs and how the interact and relate when it comes to patient care, this will help in establishing a plan that will help the hospital provide the best care, decrease in falls, pressure ulcers and pneumonia
NON-COMPLIANT TRENDS
In Joint Commission, the stated out the standards needed for an organization to be compliance with patient care and safety criterion for accreditation. In Nightingale Community Hospital, some of this policies and procedures are not rightly observed in all the units, example is the policy that clearly stated that verbal orders has to be verified within 48 hours is not being practiced in many units. Above all, the second quarter compliance was steady and of all quarters rated the best, but the compliance result for the third quarter were quite poor. Most of the policy needs revision and the standard needs improvement in other for the hospital to be in compliance. One of the policies that need to be implemented is the form the nurse that collects the order, the form has to signed, dated and placed outside of the patient's chart, bringing it to the knowledge of the physician that an action is requested from him in regards to the patient.
The most commonly two used error abbreviation are "qd" and "cc" and both are the two abbreviation that are being monitored in ICU,Telemetry,3E and 4E . From the audit, it is stated that in the months of April and September, "CC" were commonly used. The 2nd and 3rd quarters were the period the two forbidden abbreviations were frequently used. In creating awareness of the forbidden abbreviation, there should be a post stating a list of the forbidden abbreviation in the nursing station where it will be very visible for the staffs to view especially where the charts is placed. There should
Running head: ACCREDITATION AUDIT- TASK 4
be a training and education for the staffs, regarding the approved abbreviation by the Joint Commission. Furthermore, staffs should sign and date the patients chart after documentation.
Another standard that is not compliance with the Joint Commission standard is the pain assessment audit. The units focused on the ED, 3D, and PACU for this particular audit. When it comes to emergency department, it is seen as the minimal compliant all year round for pain assessment. This could be because of the urgency and life-threatening situation in which pain assessment might not be considered as a major priority. There should not be any reason for neglecting pain assessment because it is one of the accreditation requirements. Every assessment needs documentation in the patients record care file. All Nurse Managers of every department is in position to carry out and execute a plan based on the exact department level of care.
Safety is a primary focus in joint commission. At NCH, safety is handled as one of the most important, and its policies and procedures are often reviewed to certify that the hospital is...

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