examination of its policies and practices to keep up with the latest Joint Commission standards. Clinical practice is constantly affected by changes in the health care system and other factors. It is the responsibility of the hospital to be aware of such changes and modify its practice and align its goals in order to better serve the community at large. In short, it means the hospital needs to maintain compliance with the Joint Commission standards and provide consistent and quality care to its recipients
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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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Tracer Patient Audit AFT2 Accreditation Audit October 10th, 2014 Tracer Patient Audit With an audit by the Joint Commission (JC) in the near future, Nightingale Community Hospital (NCH) is performing a tracer patient survey to measure our compliance and identify issues that are in need of remediation. The practice of this type of survey tracks a patient’s care for the duration of their stay starting from the admission process and ending when they are discharged. This system allows
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Running Header: Task I 1 Task I Abigail M. Garcia Western Governor’s University: Accreditation Audit Running Header: Task I 2 Executive Summary Nightingale Community Hospital is committed to providing quality care and aims to be the first choice hospital for patients in the community. Four core values represent the passion Nightingale has for excellence: Safety, Community, Teamwork and Accountability. The goals of the hospital are to uphold an atmosphere of healing, promote the benefits
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focus area that is evaluated in this summary. Communication is a key focus area of the joint commission audit and is also a key area in which Nightingale Community can make enhancements. Communications must be a two way free flow of information. The information exchanges occur between providers, staff, and patients or clients. This was an area that needed improvement was noted in the previous accreditation audit. Some noted prior issues from 2 years ago included patient and family education and information
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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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“pre-procedure verification, site marking, and a time out performed immediately prior to the procedure.” (Maureen Burger RN, 2011) In Joint Commission standard: UP.01.01.01 the hospital is to “implement a preprocedure process to verify the correct patient.” The standard goes on further to state that the hospital identify the items that need to be available for the procedure, (Commission, 2011) In response to this Nightingale has implemented a preprocedure hand-off check list that asks several questions that
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Discuss the current compliance status of the healthcare facility. Nightingale Community Hospital is compliant with The Joint Commission standards except the following areas: Accreditation function of environment of care and life safety, it was documented that more than 3 smoke wall penetrations were found on the 1st floor and one on the 4th floor. The hospital is to minimize the potential for harm from fire, and smoke (TJC, 2013). A review of documentation showed appropriate ILSM was not initiated
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Introduction In preparation for an accreditation audit, I will discuss the current communication compliance status of the organization based on the Nightingale Community Hospital’s previous Joint Commission Survey. A corrective action plan will be submitted to ensure compliance with the Joint Commission along with a brief summary on why a communication review is important to the hospital. Body A. In reviewing the Joint Commission (TJC) survey results on Nightingale Community Hospital from 2
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Nightingale Community Hospital (NCH) is a 180-bed hospital, acute care, not-for-profit hospital that prides itself in quality healthcare. In thirteen months, NCH will face their next Joint Commission audit, and based on current findings and statistics they will need to make some adjustments to be compliant. While Joint Commission will address all the Priority Focus Areas: Infection Control, Communication, Medication Management, and Information Management, this summary will concentrate on areas in the Communication
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