Executive Summary of Accreditation Audit June 2012 I prepared and reviewed an accreditation audit for Nightingale Community Hospital to organize and ensure compliance with Joint Commission standards for our hospital. We are preparing for a site visit that should occur within the next 13 months. I have reviewed the current compliance status of our hospital and will explain our corrective action plan that will ensure compliance with the Joint Commission standards for the focus area of communication
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Jenny Windler Student ID: 000329547 Accreditation Audit (AFT2) Task 1 A. Compliance Status Nightingale Community Hospital is a complete and leading healthcare facility that believes in providing the best quality care to all of their patients. As part of Nightingale’s mission to put the patient first, the hospital must meet medication management standards set forth by the hospital and the Joint Commission. Medication management often involves the efforts of multiple services and disciplines
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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
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Accreditation Audit AFT Task 4 Regulatory Audit Organization Plans Compliance Facility Compliance The following represents the level of compliance in the pain assessment area of patient care that was audited for Nightingale Community Hospital: There were 3 departments audited for Pain Assessment compliance over a 12 month period, NIGHTINGALE COMMUNITY HOSPITAL averaged 86.94% compliance. Audit | Audit Period | Location | Compliance % | Pain Assessment | 12 Months
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Regulatory and Compliance: Hospital Communication and Wrong Site Surgery Prevention March 21st, 2014 Accreditation Audit Regulatory Audits and Compliance Hospital Communication and Wrong Site Surgery Prevention Background: Wrong Site Surgery is costly and horrifying experience for the patient, the physician and the hospital. It is considered a preventable medical error. In 1999, the Institue of Medicine report, To Err is Human states that “clinicians were unaware of the number of surgery-associated
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A1- Sentinel Event A 3 year old female patient was admitted to the Ambulatory Surgical Unit for an outpatient procedure to place tubes in her bilateral ears. The patient’s mother was advised that the procedure would take approximately 45 minutes and that the patient would remain in recovery for at least an hour. The patient’s mother advised that she needed to leave the facility to deal with an older child and gave Greta, the pre-op nurse, her cell phone number and asked that she be contacted
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RAFT –Task 2 Root Cause Analysis A-1. Sentinel Event A sentinel event is an event that happens expectantly in a healthcare facility that could result possible death, physical or mental injury to patients unrelated to natural causes of the patients illness as defined by Joint Commission (www.joint commission.org). On the afternoon of Thursday, September 14, at approximately 12:30 p.m. a ‘Code Pink’ (child abduction alert) was called when a minor child/patient, Tina, was discharged to the care of her
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Executive Summary Hospital compliance status for Nightingale Community Hospital Nightingale Community Hospital (N.C.H) has, for a number of years, been the hospital of choice for patients and family who seek superior and excellent and professional care for themselves and their loved ones. As a premier hospital in the region, it has a reputation of having an unwavering commitment to constantly improve its standards of operation so that its patients can always be assured of having unsurpassed healing
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A. Compliance Status When a patient checks into Nightingale Community Hospitals they believe the hospital will put there care first and provide quality medicine. Looking at the recent compliance reports there are areas of patient care this hospital needs to improve in. Reporting critical results within 60 minutes, labeling medication containers and reactions with anticoagulation therap.0y are areas that this hospital needs to improve upon. Improving these areas would be just one step toward
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SENTINEL EVENT This is a case of an inpatient admitted at the Nightingale Community Hospital for a medical procedure which by all standards was a success but the patient is discharged from the hospital without the knowledge of the mother culminating into a sentinel event. Joint Commission (commission, 2013) defines a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury or the risk there of. Serious injury specifically includes loss of limb or
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