Continuous Accreditation Compliance - Task 4

AFT2 Accreditation Audit

October 31st, 2014

Continuous Accreditation Compliance - Task 4

Nightingale Community Hospital (NCH), like many other health care facilities, uses a Periodic Performance Review (PPR) as an assessment tool that assists in examining performance on a consistent basis to ensure compliance with Joint Commission standards. A PPR concentrates attention on procedures, methods, and processes that contribute an environment that provides for proper care and emphasizes patient safety. NCH has shown to be 100% compliant with the majority of standards including: Infection Prevention and Control, Right and Responsibilities to Patients, Human Resources, Transplant Safety, Emergency Management, and Performance Improvement. During the last inspection NCH was found to be non-compliant in the following areas: National Patient Safety Goals, Record of Care, Environment of Care, Nursing, Treatment and Services, Leadership, Life Safety, Provision of Care, and Universal Protocol.
Trending Areas of Concern The PPR revealed numerous issues in all areas of NCH. In order to address issues that affect patient safety and accreditation it is necessary to focus on issues that are found to be present in several areas of the facility. These patterns and trends of non-compliance often expose a weakness in policy, procedure, or training that needs to be addressed in order to ensure patient safety and accreditation compliance standards are met. The PPR identified the following trends of non-compliance: verbal orders authenticated in a timely manner, prohibited abbreviations, lack of proper documentation, and clutter in hallways. The PPR also identified a particular area of NCH, 3E, which had an increased amount of issues as compared to other departments.

Verbal Orders Authenticated in Timely Manner