...The focus of the Joint Commission is patient care and organizational functions that are necessary to provide a high quality of care without putting patients, individuals, or residents in harm. That is why it is very important for organizations to follow the standards outlined. As Diane began to prepare for the Joint Commission visit, she found several deficiencies in Willow Bend Hospitals’ policy that needed attention. • Standard IM .02.02.01-Collection of Health Information states the hospital effectively manages the collection of health information and uses uniform data sets to standardize data collection thought-out an organization. According to the survey readiness scenario for Willow Bend, the use of abbreviations and medical terminology fall within this standard. As Diane reviewed the policies she finds a policy addressing the use of medical terms and abbreviations, but what she doesn't find is specific information as to who is responsible for maintaining the list and making it available to the end users. Diane should reach out to the IT department to see if there is a separate policy or a list of users’...
Words: 810 - Pages: 4
...Write an essay discussing the following 1. The role of the Joint Commission in accrediting medical facilities The Joint Commission was designed to help to improve the quality of patient care by assisting international health care organizations, public health agencies, health ministries and others evaluate, improve and demonstrate the quality of patient care and enhance patient safety in more than 60 countries. The Joint Commission seeks to continuously improve health care for the public as well as the primary standard in the healthcare industry. 2. Which facilities can be accredited? Upon doing a review of the type of facilities that receive accreditation from Joint Commission accreditation, I’ve found over ten . Joint Commission accreditation can be earned by health care organizations such as hospitals, doctor’s offices, nursing homes, office-based surgery centers, behavioral health treatment facilities, and providers of home care services. I also noticed those facilities such as behavioral health care organizations, addiction services; rehabilitation centers, group practices, office-based surgery centers and other ambulatory care providers; and independent or freestanding clinical laboratories . 3. What are the goals of the Commission? The purpose of the Joint commission is to minimize data collection efforts while using the data to improve the health care delivery process. The joint Commission uses National Patient Safety Goals when determine if goal are...
Words: 1278 - Pages: 6
...very unique comparable to the healthcare in other nations. As American healthcare continued to grow and expand, so did the growth of insurance, the involvement of governmental ties, dependency of advancing technology, and the expenditures of what healthcare would bring upon the American people. This brought about the greater need for accountability for services rendered at that healthcare institution (Morrison, 2011). Healthcare regulatory agencies have also had to keep up with the evolving healthcare fields. American College of Surgeons started a standardization of practices in the healthcare fields. This later developed with various other adjoining forces into what we know today as the Joint Commission on the Accreditation of Hospitals. In 1987, this evolved into the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). This accrediting agency had influences among the ambulatory care, assisted living, home health, behavioral, health, laboratories, long term care, and office based surgeries (Morrison, 2011). JCAHO was developed to set a standard of care that held these services accountable for. This helped to have hospitals provide the same level of quality care to the people they served from the community. This in turn provided safe care to the patients. During the initial stages of accrediting when JCAHO was first developed, they would base their results on hospitals self-scoring. Time passed on, hospitals grew and the status of being JCAHO...
Words: 1530 - Pages: 7
...AFT Task 4: Periodic Performance Review Accreditation Audit Case Introduction The accreditation process is designed to assist healthcare establishment to identify and enhance the patient’s safety and the quality of service delivery. This paper presents a review of the readiness Nightingale Community Hospital for accreditation audit. The paper comprises of a periodic performance review of the establishment. The review has focus of several priority areas. These areas include; assessment and care; quality improvement; patient safety, and staffing effectiveness. Trend within the hospital indicates the Nightingale has made significant progress towards fulfilling the standards of the Joint Review Commission. However, the trends in staffing effectiveness are limiting the organization’s compliance. Periodic Performance Review (PPR) The PPR is based on data collected in the Joint Commission Survey. The survey utilized the priority focus methodology to evaluate the compliance of Nightingale Community Hospital. The priority focus process is a methodology that makes use of data to establish priority areas for reviewing compliance. This process has utilized of both external and internal data to evaluate the compliance of Nightingale Community Hospital. This methodology identified several priority areas. These include; assessment and care services; quality improvement activities, and patient safety. This paper evaluates Nightingale’s compliance in these three priority areas. Compliance...
Words: 2525 - Pages: 11
...that provides a myriad of services for our local community. From our state of the art Vascular Lab to our Neuroscience Unit we strive to provide cutting edge technology with exceptional care. Our vision is to be the hospital of choice for patients, employees, physicians, volunteers and the community. Our mission is to create a healing environment, with a passionate commitment to healthcare excellence. Through our vision and mission, Nightingale Hospital strives to meet and exceed all expectations during our next Joint Commission visit. Before we address the aspects of our upcoming visit from Joint Commission, we must address the foundation of what Joint Commission is. One of the definitions of Joint Commission is, “Joint Commission Accreditation of Healthcare Organizations (JCAHO) is an organization that develops and maintains standards to promote compliance in regards to acceptable levels of care that should be given to patients” (About the Joint Commission). Accreditation from JCAHO provides Nightingale Community Hospital with the gold seal of approval signifying exceptional care. Currently Nightingale Hospital has the JCAHO stamp of approval. However we as an organization should strive to achieve a higher standard of care for our employees and patients as well as our community. With the upcoming visit from JCAHO approaching we need address the past JCAHO visit and pay attention to some of our deficiencies. Our priority focus areas for our facility will be:...
Words: 1123 - Pages: 5
...During the last Joint Commission survey two years ago, there were several areas of deficiency surrounding the use of moderate or deep sedation or anesthesia. These noted deficiencies gave Nightingale Community Hospital the opportunity to revamp and strengthen our procedures in all areas of peri-operative services. These include the Main OR, CVOR (Cardiovascular OR), Interventional Labs (Cardiac Catheterization and Interventional Radiology), and Endoscopy Suites. Significant process has been made especially in the area of the Time Out. A Time Out is the step by which all work in the particular surgical area halts and everyone in the suite actively participates in ensuring that for the current surgery we have: 1. Correct patient. 2. Correct side and site. 3. Correct procedure to be done. 4. Correct patient position. 5. Correct implants and equipment. All of the Peri-Op services procedural areas brought members of their teams to participate in brainstorming and development sessions in the area of the Time Out to ensure that it was robust and all encompassing. As well, some of these components and other important details should actually be completed prior to the patient’s arrival in the surgical suite. While the Time Out is an effective last act before a surgery proceeds, many other details should and must be completed long before that. This ensures the safety of the patient and our staff. This has led to significant improvements under the Joint Commission standards for...
Words: 966 - Pages: 4
...Joint Commission Eligibility for Hospital Accreditation, the organization must be in the United States or its territories, or if outside the United States, is operated by the U.S. government or under a charter of the U.S. Congress. For all programs by law the organization has a facility license or registration to conduct its scope of services. The organization can demonstrate that it continually assesses and improves the quality of its care, treatment, and/or services. .The organization identifies the services it provides, indicating which care, treatment, and/or services it provides directly, under contract, or through some other arrangement. The organization provides services that can be evaluated by Joint Commission standards. If the organization uses its Joint Commission accreditation for deemed status purposes, the organization needs to meets the Center for Medicare and Medicaid Services. The organization must meet parameters for the minimum number of in patients/volume of services required for organizations seeking Joint Commission accreditation for the first time. A hospital that is seeking Medicare Certification and is new to The Joint Commission must have one active inpatient case at the time of survey. If the hospital’s Average Daily Census is 21 or more, or if the hospital is a specialty hospital (cardiac, orthopedic, or surgical), the hospital must be able to provide inpatient records for at least 10 percent of the average daily census, but not less than 30 inpatient...
Words: 1230 - Pages: 5
...AFT Task 3 As our Joint Commission audit approaches, Nightingale Community Hospital has conducted a tracer patient survey to assess our compliance. The tracer methodology tracks a selected patient's care from admission to discharge, allowing us to evaluate our systems of providing care and to ensure that we are meeting the Joint Commissions standards of providing safe, quality healthcare. Our tracer patient was a 67 year old female who presented with a fever and drainage five weeks after an open hysterectomy. She was admitted for a suspected postoperative infection,. She underwent another surgery to treat the abscess that formed from the initial surgery and had a central line inserted for long-term antibiotics. She is scheduled to go home with home health overseeing her antibiotic therapy. This tracer patient has shown that there are areas of our patient care that we need to improve upon in order to be in compliance with the Joint Commission standards. According to The Joint Commission (2014) compliance with standard PC.01.02.03 requires that a history and physical examination be done within 24 hours of inpatient admission and prior to surgery. In the case of this tracer patient, the history and physical was completed more than 72 hours after admission. Further, this patient underwent surgery two days after admission, prior to the completion of a history and physical exam. The history and physical examination is a very important tool in a patient's care....
Words: 610 - Pages: 3
...experience for all. Overview In order to reach the aforementioned goals, values and commitments, Nightingale Community Hospital must be in compliance of regulatory agencies which outline specific, goaloriented sets of standards. The Joint Commission is one such agency that provides assistance and support to health care facilities to ensure that certain standards are met, education for implementing new standards and feedback of current healthcare practices as part of the accreditation process. According to Facts about Hospital Accreditation (2014), the “Joint Commission standards address the hospital’s performance in specific areas, and specify requirements to ensure that patient care is provided in a safe manner and in a secure environment (p. 1).” This agency uses a Priority Focus Process methodology to identify areas within healthcare organizations which have a significant impact on patient safety and quality of care. One of these areas that Nightingale Community Hospital would like to focus on is communication. According the O’Daniel and Rosenstein (2008), “Lack of communication creates situations where medical errors can occur. These errors have the potential to cause severe injury or unexpected patient death…More specifically, the Joint Commission cites communication failures as the leading root cause for medication...
Words: 2426 - Pages: 10
...choice for all and a mission to create a healing environment with a passionate commitment to health care excellence. This executive summary of the accreditation audit is presented to the senior leadership to outline the compliance, plan of compliance and institution of the hospital under the reviewed focus area of Information Management as per the Joint Commission Standards. COMPLIANCE STATUS. The Joint Commission Standard IM 02.02.01 requires that the hospital effectively manages the collection of health information. Nightingale Community Hospital is in compliance with this standard under its patient care policy which specifies prohibited abbreviations. Its policy states that the use of abbreviations and symbols in the medical record is discouraged to prevent errors; as these can be associated with misinterpretation resulting in medical errors, and patient harm. In case the intended meaning of the abbreviation or symbol in the context of a specific order is not clear, the ordering practitioner must be contacted for clarification. This procedure demands that the elements of performance under IM 02.02.01 of the Joint Commission accreditation requirements are adhered to; 1. That the hospital uses uniform sets to standardize data collection throughout the hospital; The findings by the Director of accreditation notes that this standard is not indicated anywhere in the hospital’s policy, admission orders and national patient control goal data of its information management...
Words: 1726 - Pages: 7
...resulting in injury, damage, or loss of life. Physicians have insurance for this in case an incident occurs. Physicians follow a code that states do no harm but sometimes harm occurs due to their negligence to underlined issues. If underlined issues dealing with your diagnosis is not checked out then it can lead to further injuries and even death. Medical malpractice can cost a facility or hospital millions even billions of dollars each year. Medical malpractice not only will cost money but it can also hurt a hospital or facility reputation for treatment for patients. Medical malpractice cases require stringent and comprehensive clinical review, and hospitals always employ medical experts to review their cases. The clinical issues are always analyzed, but often overlooked is the evaluation of the corporate responsibilities of the hospital involved in the matter. It is becoming increasingly likely that the hospital will be included in the claim as plaintiff attorneys are very aware that courts are finding corporate negligence as a factor in many claims, and more and more states are recognizing corporate negligence as a contributing issue (Steinberg, Becker Hospital 2012). Dr. Steinberg states “As a consultant and expert witness, I see many cases that could be avoided with some thoughtful review and analysis. Typically, the cases I review are either related to the hospital not following Joint Commission standards, either by ignoring required policies and procedures, or physician credentialing...
Words: 804 - Pages: 4
...patients can always be assured of having unsurpassed healing and care services in the hospital. In line with its mission to provide and assure patients of its commitment to the provision excellent care and services to its patients, N.C.H gets the joint commission periodically to come in and rate all the departments as well as the quality of care that the hospital provides. This evaluation by the joint commission is important because its seal of endorsement on a hospital means that the hospital rates highly in all aspects of care. Patients and their families constantly look for that supreme seal of excellence. Therefore N.C.H wants to make sure its services measure up to the joint commission standards. The previous findings by the Joint commission showed that there was a problem with communication in the hospital. It revealed that even though there were policies in place to ensure that information is efficiently passed across the channels, the leadership had not properly educated the staff to effectively utilize this information in providing superior care to their patients. It also revealed the inadequacy in their documentation processes which poses a potential threat to patient care and safety. In preparation for the upcoming visit by the joint commission’s staff to re-evaluate the hospital and its services, Feesah’s consulting group was contracted to determine the hospital’s present status of compliance with regards to the...
Words: 1222 - Pages: 5
...Patient and Family Centered Care Kimberley Masterson WGU0713 Stacy Stratton-Mentor Practice Setting Wellington Regional Medical Center is located in Wellington, Florida. It is a 233-bed, acute-care hospital, owned by a subsidiary of Universal Health Services, Inc., a highly respected, healthcare management organization. Wellington Regional Medical Center is owned and operated by a subsidiary of Universal Health Services, Inc.(UHS), a King of Prussia, PA-based company, that is one of the largest healthcare management companies in the nation. Wellington Regional is proud to have provided high-quality healthcare("About Wellington Regional Medical Center - Palm Beach, FL | Wellington Regional Medical Center," n.d.) services to the residents of Palm Beach County since 1986.The Village of Wellington has an approximate census of 60,000 in 2013. (Census.gov). Wellington is located in western Palm Beach County and borders the Florida Everglades. Initially, the land area known today as Wellington, Fl. was developed in 1953 to provide drainage and flood control suitable for agriculture. The area was once the world’s largest strawberry patch. Nevertheless, over time the land has been purchased and sold until 1985 when Lennar homes built on 500 lots. Today, Wellington is an affluent and thriving community that is willing to stake its future on being different.(“Wellington/History of Wellington”.nd) Wellington is recognized as the winter equestrian capital of the world. Wellington...
Words: 6407 - Pages: 26
...Nightingale Community Hospital A. Compliance Status Nightingale Community Hospital (NCH) has a vital role as a not-for-profit community hospital providing health care and services in various areas such as critical care, general medical and surgical services, oncology etc. This executive summary provides overview in terms of NCH`s compliance of priority focus area on communication: * The current status of the NCH`s communication compliance with the communication requirements of the Joint Commission (JC) on Accreditation of Healthcare Organization. * Corrective action plan for a compliance with the JC’s standards for the communication focus area. * Justification of an importance for the communication standards for NCH. Current Status NCH Communication standards compliance to 2013 Joint Commission Hospital Standards for Communication NCH current standards and protocols in place | Joint Commission(JC) Standard Number | Joint Commission Standards, retrieved from Joint Commissions on Accreditation of Healthcare Organizations (2013) | NCH Preprocedure Hand-Off form | UP.01.01.01 | Conduct a preprocedure verification process. | Overall finding: Based on the provided material, NCH preprocedure hand-off form, there appears to be a preprocedure verification process in place within the hospital. This form, however, does not have a clear division of information areas that are collected and the data provided is not completely compliant with JC to provide a full list of...
Words: 3976 - Pages: 16
...A. Compliance Status The following executive summary focuses not only on the identified gaps in the current process, but also the corrective action plan to support compliance in the noted areas of the Communications Standards as provided by The Joint Commission, (National Patient Safety Goals, 2013). The high risk associated with surgical procedures performed on the wrong site has driven a risk mitigating approach to the processes involved for these procedures. The goal is to prevent harm to patients having a surgical procedure. The following summary is the current compliance status if the Priority Focus Area of Communication for Nightingale Community Hospital. After review of the specific areas identified in the Priority Focus Area, the following have been identified as requiring further attention: time-outs are routinely performed prior to every procedure (UP 01.03.01) and procedure site is marked (UP 01.02.01). Based on the evaluation of the Nightingale Community Hospital National Patient Safety Goals for Communications the current compliance rate related to the Universal Protocol Time-Out processes performed hospital wide indicate a 95% to 100% compliance rate for the year. The graph provided in the Nightingale Community Hospital National Patient Safety Goals Communication assessment provides limited information as these are hospital wide percentages. No unit specific evaluations of performance have been provided in the report. Upon review of the Site Identification and...
Words: 2795 - Pages: 12
