A. Compliance Status
The Joint Commission, JC, conducts reviews to provide accreditation to facilities based on compliance with federal and state rules and regulations as well as the accrediting body’s standards. The Accreditations Audit Case Study on Nightingale Community Hospital, NCH, for this task is based on documentation reviewed and pre-survey data collection thirteen months prior to the next Joint Commission review. This discussion provides an executive summary and current compliance status for one priority focus area for NCH as well as Plan of Correction and Justification for the needed actions.
JC standards outline priority focus areas in the areas of Assessment and Care/Services, Quality Improvement Expertise/Activities, Communication, Infection Control and Patient Safety.
For the purpose of this discussion, the Primary Focus Area of Communication will be discussed as it pertains to NCH. The JC Standards identify communication as the process for information exchange between organizations, departments, or individuals. This includes provider and staff communication, staff-to-patient communication, patient and family education, collaboration of services, multidisciplinary team work, and information dissemination. In preparation for the JC accreditation review, NCH reviewed the JC Communication standards pulled from UP.01.01.01; UP.01.02.01; and UP.01.03.01 and compared against the NCH policy and operations as well as data collected through the General Safety Report. 1. UP.01.01.01 is the JC standard outlining requirements to execute a pre-operation verification process. a. JC Standard identifies this operation to ensure any operation performed is the accurate operation, performed on the accurate person, and on the accurate area b. The following Joint Commission Performance Measures are outlined to maintain compliance with