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| Task 4 | | | Monica DeWitt | |

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Current Compliance Status
The hospital is compliant in with the National Patient Safety Goals (NPSG) in the following areas: staff is using 2 identifiers when providing care, correctly transfusing patients, maintaining a healthy patient care environment by complying with the Center for Disease Control (CDC) and World Health Organization (WHO) hand hygiene guidelines, continuing evidence-based best practice to prevent or reduce the risk of catheter-associated urinary tract infections (CAUTI), identifying patients at risk for suicide.
Within the rest of the accreditation requirements the facility was compliant with the following elements:
EM-emergency management
HR-Human Resources
IC-Infection Prevention and Control
IM-Information Management
MS-Medical Staff
PI-Performance Improvement
RI-Rights and Responsibilities of the Individual
TS-Transplant Safety
Trends of noncompliance within the healthcare system
From the list of recorded finding there are several trends identified in which the hospital is will need to address to meet the Joint Commission (JC) standards. The list is divided into direct and indirect impact. There are 4 indirect impact issues that need to be addressed and 1 direct impact issue.
Indirect Impact Trends
Verbal Orders-Verbal orders are not being authenticated within the 48 hours on several units. The hospital audits should show a 100% compliance regarding verbal orders. The audit shows the hospital has not been compliant during the past 12 months. The highest percentage was 90%. On 3E, 4E, ED, PI data and telemetry are the area where improvements need to be made.
Clutter in the hallway-Clutter in the hallways creates a risk to patients and staff. The units sited for this include 3E, 4E, OR and telemetry.
Reassessment-Not performing an assessment before

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