Accreditation Audit

In: Business and Management

Submitted By terribear11
Words 3063
Pages 13
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 increasing patient care and satisfaction at this hospital. There are three areas to focus on that Nightingale Community Hospital is not in compliance with according to the Joint Commission standards. These areas are reporting critical results within 60 minutes, labeling medication containers and relations with anticoagulation therapy.
One is in reporting of critical results hospital-wide. The survey results showed the hospital’s average in regards to reporting critical results within 60 minutes was 70% of the time. In the survey there were only three months August, October and December, where the hospital scored in the 80% or higher range. All other months they scored between 56% and 78%. To be in the Joint Commission standards the hospital’s scores should be in the 100% range. The Joint Commission survey results showed that three of the staff nurses that were interviewed indicated the leaders had not effectively communicated to the nursing staff Nightingales reporting policy. (The Joint Commission: LD.04.01.05, 2012) This shows that commutation is an improvement item this hospital has to add to their correction plan. Nightingale Community Hospital needs to fix their poor communication among staff members hospital-wide. The introduction of a monitoring system to improve communication and emphasize team members roles in reporting critical values will increase quality…...

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