...Running head: NIGHTINGALE INFECTION CONTROL STATUS Nightingale Infection Control Status Daniel Pennebaker Western Governors University, College of Business Abstract This executive summary will judge the status of Nightingale Community Hospital’s Infection Control performance against the Joint Commission’s accreditation standards. The summary will include a corrective action plan designed to aid Nightingale in meeting all standards. Nightingale Infection Control Status Executive Summary TASK A Accreditation Audit Consultants was asked to provide a review and corrective actions plan for each of the Joint Commission Primary Focus Areas as part of Nightingale Community Hospital’s Re-Accreditation readiness program. While each of the Primary Focus Areas will be reviewed, this Executive Summary will cover Nightingale’s performance in the Infection Control PFA. Using the Surveillance Objections document created April 23rd and comparing that to data collected over the course of the year the following successes and areas to be improved are noted. Hand Hygiene, one of the four main areas for Infection Control as listed in the Joint Commissions Standards for Infection Control, is performing above the goal stated in the Surveillance Objectives documents. The goal stated is >90% and Nightingale is clocking at a hospital-wide 92% with even higher observed compliance scores for Physicians (94%) and Ancillary Providers (96%). While this success is to be applauded it should...
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...Running head: ACCREDITATION AUDIT- TASK 4 COMPLAINCE STATUS Joint Commission clearly explained that a Periodic Performance Review is as an assessment tool designed to help in assisting the healthcare organization contributes greatly in the improvement and monitoring performance all through the year. The periodic performance focuses more on the measures that has to do with patients safety and care and at same time given the facility for unremitting standards fulfillment. NCH is 100% compliance with most standards of Joint Commission in the following area; Emergency Management, Human resources, Infection Prevention and Control, Performance Improvement, Right and Responsibilities of the Individuals, Transplant Safety. During the inspection at the facility, the hospital was found to be non- compliant in this listed areas; Environment of Care, Leadership, Life Safety, universal protocol, Medication Management, Medical Staff, National Patient Safety Goals, Nursing, Record of Care, Treatment and Services, and provision of care During the PPR, the hospital was found with an increase cluster in the hallways, it is a fire hazard and a safety issue. The nurses are not familiar with verbal order procedures, using the range of orders that received and the abbreviations that are prohibited in the documents. From the trend, there are areas at which the hospital needs to implement proper education and audit. An action plan needs to be implemented by the administration to address the fallout...
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...providers, the ethical implications involved in healthcare decisions, it is nearly impossible to define the “right” amount to be spend in healthcare. As our nation is debating what the appropriate amount to be spend on healthcare is, this project aims on understanding the drivers for this high cost and possible ways to control them. One of the important drivers for this high healthcare cost that we identified and will discuss in this paper is unnecessary care. Although there are number of factors contributing to unnecessary care, this paper focuses on four key issues mainly sterilization, hospital acquired infections, medical errors and hospital readmissions. Sterilization: Background of the issue Hospitals are hygienic paradoxes. It is where patients are cured from diseases and acquire a new one. Hospital hygiene is difficult to achieve. According to the World Health Organization estimates, “more than 1.4 million people worldwide are affected by infections acquired in hospitals” (Cleanhospitals.net). Why are there so many unclean hospitals and what body of people holds them accountable for medical negligence? How do you eliminate hospital-acquired infections (HAIs) and improve hospital hygiene standards? Current status and challenges Currently, many hospitals clean, disinfect, and sterilize hospital equipment. While hospital staff and nurses may be able to be trained on the proper cleaning procedures, equipment sterilization is not a part of the nursing staff’s...
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...The Joint Commission is a nonprofit organization that certifies more than 18,000 health care organization and programs throughout the world. Founded in 1951, the Joint Commission provides a national symbol of quality for health care as well as analyzes each organization’s commitment to meeting high quality performance standards. The Joint commission focuses on accrediting Acute Care Hospitals, ambulatory, behavior health, long term care, health care facilities, clinical laboratories, health care networks and hospice. Numerous of accreditation organization is also taking place within the United States, but the Joint commission remains the largest The Joint commission accredits 20,000 organization” which” one third are Hospitals. The joint commission is assigned a special task to improve health care by evaluating health care of organization as well as encouraging health organizations to provide safe and effective care at the highest level. The Joint Commission believes that the only way to improve the quality of health care is to join together with other stakeholders and evaluate each health care organization. The Stakeholder consists of 29 broad members of commissioner and cooperate members such as the American Hospital Association, and the American Medical Association. In this paper I will analyzes key topics such as the Joint Commission source and its scope of authority, the structure of the Joint commission and how its responsibilities. The Joint Commission Structure ...
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...Joint Commission Action Plan Accreditation Audit – AFT2 Task 1 Nightingale Community Hospital is a 180 bed hospital that prides itself in creating the most cost effective place to heal in the comfort of the most compassionate staff of excellence. Nightingale Community Hospital is thirteen months away from a visit from Joint Commission. The four identifying factors that we need to focus on are four areas: Information Management, Medication Management, Communication, and Infection Control to avoid falling out of compliance. I have chosen to provide an executive summary outlining the current compliance status of Nightingale in Information management. The world has been continuously transformed through various technological advances in various fields. One of those technological advances has been a great adaptation in healthcare, which is the use of EHRs (Electronic Health Records). Accurate and complete patient information is accessible to providers to improve their ability to make treatment decisions in a timely manner. All the administrative and all the clinical data are accessible in the EHR (Dimick, 2012). EHRs are more concise and accurate than paper charts because it allows for quick retrieval of various test results, allergies, problems, illnesses, infections, and procedures that the patient may have had in the present or past. Charts rarely go missing and the EHRs have been very cost effective. Nightingale has...
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...It was stated in our reading material that the Gallop poll rated Nursing to be the most ethical profession and expecting nursing professionals to illustrate the highest ethical standards from any industry. Nurses are held accountable for the patient and their family’s welfare. The ANA provides the Nursing profession guidelines to treat every patient with dignity, respect, and compassion also free from any personal judgment of race, social or economic status, personal disparities, or disregard to health status. The American Nurses’ Association illustrates how to carry out your professional practice with their primary focus on the patient and their family. As nursing we must respect professional boundaries, to include the privacy and confidentiality of the patient and family. Nurses must maintain a respect for human dignity, and hold in the patient as the primary focus. (ANA, 2015). The nurse’s duties include the responsibility to follow guidelines and regulations, acting only on duties within the scope of the professional practice. Also, any nurse who maintains licensure in any state must also adhere to the regulations and their respective boards. The ANA creates community for an ethical culture so that nurses can deal with the daily ethical decision-making, so knowing how the organizational culture will affect those decisions is important. Nurses have certain standards to go by and if they are not making the right choices he or she are violating their professional ethical...
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...BTEC Level 2 Certificate, Extended Certificate and Diploma in Health and Social Care (QCF) Unit 7: Anatomy and Physiology for Health and Social Care Assignment 7 Contents Index | | Page No | Learner details* | | 3 | Learner tracker* | | 3 | Learner declaration* | | 3 | Aim and purpose | | 4 | Unit introduction | | 4 | Learning outcomes | | 5 | Unit contents | | 7 | Essential Resources | | 8 | Assessment brief | | 9 | Task 1 | P1 | 10 | Task 2 | P2/M1/D1 | 10 | Task 3 | P3 | 11 | | | | Task 4 | P4/M2 | 11 | Task 5Task 6 | P5P6/M3/D2 | 1112 | | | | | | | * Must be submitted with learner’s evidence. Assignment 7 – Unit 7: Anatomy and Physiology for Health and Social Care Learner Name: Assessor Name: Issue Date: Deadline Date: Submission Date: Learner Tracker Assignment 1 | Assessment Criteria | Completed | Grade | Task 1 | | | | Task 2 | | | | Task 3 | | | | Task 4 | | | | Task 5 | | | | Task 6 | | | | ------------------------------------------------- Learner Declaration ------------------------------------------------- The learner declaration must be attached to the completed portfolio of evidence. ------------------------------------------------- Learner Name: ------------------------------------------------- I declare that the work contained in this portfolio of evidence is all my own work. ------------------------------------------------- ...
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...Executive Summary Joint Commission Standards Compliance Prepared by: AK- Joint Commission Priority Focus Area: Communication RAFT Task 1 The Joint Commission Priority Focus area for Nightnigale included the four areas: • • • • Information Management Medication Management Infection Control Communication All these priorities focus on the national patients safety goal as the most important in patient management and treatment, and guide the hospitals toward appropriate policies and protocols to follow and to minimize any possible mistakes or patients harm. I choose the priority focus area of Communication to discuss the current compliance status of our organization concentrating on the standards, which did not meet the Joint Commission requirements, and then suggest a corrective action plan to reach the goal of full compliance with the Joint Commission Accreditation. Communication Focus Area Compliance: Current Compliance Status: Despite the written policy and emphasis on the communication between all medical staff, patients, families, some elements did not meet the Joint Commission standards including the following: 1. Reporting Critical Results within 60 minutes: Goal is 100% compliance. • • • The importance of this element in patient management makes it so critical to have a better outcome and reduce complications and bad outcomes. Our institution compliance averaged 56% to 82% depending on the month. Some of the reasons for delayed reporting was identified as follows:...
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...Healthcare Risk Control Risk and Quality Management Strategies 4 Executive Summary VOLUME 2 July 2009 Key Recommendations Assess current activities in risk management and quality improvement to evaluate their effectiveness in addressing overlap. Establish a structure to ensure that patient care activities are addressed in a coordinated manner involving risk management and quality improvement functions. Seek legal counsel to ensure that the structure for risk management and quality improvement activities maximizes legal protections granted by state and federal statutes while allowing for the flow of information. Align risk management and quality improvement plans with the strategic goals of the organization. Educate stakeholders on the role of risk management and quality improvement functions. Design systems to coordinate and streamline data collection, analysis, monitoring, and evaluation. Risk Management, Quality Improvement, and Patient Safety In the past, the risk management and quality improvement functions often operated separately in healthcare organizations and individuals responsible for each function had different lines of reporting—an organizational structure that further divided risk management and quality improvement. Today, risk management and quality improvement efforts in healthcare organizations are rallying behind patient safety and finding ways to work together more effectively and efficiently to ensure that their organizations deliver...
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...it means the hospital needs to maintain compliance with the Joint Commission standards and provide consistent and quality care to its recipients. Compliance is a difficult task to achieve. It requires great effort on the part on the administrators and work force and requires the collaboration of interdisciplinary teams to bring about the desired effect. In order to monitor compliance, the hospital utilizes a periodic performance review (PPR) tool to assess its performance by continuous monitoring and performance improvement activities. The PPR provides the chassis for continuous standards compliance and focuses on the essential systems and practices that affect patient care and safety. The hospital self-evaluates its adherence with all Joint Commission Accreditation Participation Requirements, National Patient Safety Goals, related Elements of Performance (EPs), and develops a Plan of Action for all areas of performance identified as being non-compliant. The hospital also develops Measures of Success (MOS) for determining whether the organization is successful in resolving identified problems. Nightingale Community Hospital provides various medical, surgical, ambulatory care, laboratory, pediatric and emergency services and is thereby accountable for maintaining compliance as per accreditation policies. Areas of...
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...Organizational Leadership and Inter-professional Team Development The Patient and Family Care Organizational Self-Assessment Tool (PFCC) for current practice setting will be completed as well as the organization in its entirety. The results will be analyzed based on a one to five scoring system with one being the lowest. The areas where the organization could improve its PFCC care will be discussed. The analysis of how business practices and regulatory requirements impact patient family centered care. A strategy will be created that includes goals and an operational plan to increase PFCC of the organization by improving one of the gaps that’s identified. I will discuss financial implications that this strategy may have on the organization. I will identify potential members for the multidisciplinary team who could assist in improving the identified gap. I will discuss the purpose and scope of the team to include the member’s roles, and importance of diversity within the team. The team will focus in a meaningful way using self-assessment, and awareness of self-reflective techniques. I will use PDAC to monitor whether the strategy was effective in increasing patient and family centered care. Self-Assessment Tool The PFCC tool was used to evaluate Medical Center Health System (MCHS) see attached. Setting Description Medical Center Hospital System (MCHS) is an acute care, not for profit regional 402 bed Level II Trauma Center, located in West Texas of the...
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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 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...
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...focused on improving surgical care by significantly reducing surgical complications. One complication is surgical site infections SCIP has developed recommendations for hair removal. There are several SCIP measures, antibiotic within one hour before incision, received prophylactic antibiotic consistent recommendations, prophylactic antibiotic discontinued within 24 hours, control of postoperative serum glucose and appropriate hair removal. (Patterson, 2011, p. 120) What is appropriate hair removal? Razors can remove hair and has been the traditional method of hair removal, powered surgical clippers can trim hair at surgical site and does not leave cuts and microscopic abrasions where microscopic Flora can colonize in the surgical site causing postoperative infection. The National Quality Forum has endorsed to SCIP infection control measures. According to the Surgical Quality Alliance, which is a collaboration among specialty societies that provide surgical and perioperative care to improve the quality of care for the surgical patients, states that” following the endorsement by the National Quality Forum SCIP measures were incorporated into Medicare's reporting of Hospital Quality data for annual hospital payment. (Corrigan, 2009, p. 79) It was also identified as the National Patient Safety goal under the Joint Commission Hospital accreditation program. As January 1, 2010 the Joint Commission considers shaving with razors an inappropriate hair removal method. There are many different...
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...| Task 4 | | | Monica DeWitt | | | Current Compliance Status The hospital is compliant in with the National Patient Safety Goals (NPSG) in the following areas: staff is using 2 identifiers when providing care, correctly transfusing patients, maintaining a healthy patient care environment by complying with the Center for Disease Control (CDC) and World Health Organization (WHO) hand hygiene guidelines, continuing evidence-based best practice to prevent or reduce the risk of catheter-associated urinary tract infections (CAUTI), identifying patients at risk for suicide. Within the rest of the accreditation requirements the facility was compliant with the following elements: EM-emergency management HR-Human Resources IC-Infection Prevention and Control IM-Information Management MS-Medical Staff PI-Performance Improvement RI-Rights and Responsibilities of the Individual TS-Transplant Safety Trends of noncompliance within the healthcare system From the list of recorded finding there are several trends identified in which the hospital is will need to address to meet the Joint Commission (JC) standards. The list is divided into direct and indirect impact. There are 4 indirect impact issues that need to be addressed and 1 direct impact issue. Indirect Impact Trends Verbal Orders-Verbal orders are not being authenticated within the 48 hours on several units. The hospital audits should show a 100% compliance regarding verbal orders...
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...December 2, 2013 RAFT Task 1 Executive Summary for Joint Commission Standards Compliance Nightingale Community Hospital is a 180-bed acute care hospital that is a not-for profit entity. The hospital is community based and provides leadership in quality health services in which they provide. Their vision is to be the hospital that people choose, the place employees, physicians and volunteers want to work and a hospital of choice for the community. They are committed to providing a healing environment to their patients with a compassionate commitment to healthcare excellence. The four main areas of focus for the Joint Commission for Nightingale Hospital include Communication, Information Management, Medication Management and Infection Control. The goal of these four focus areas is safety. The goal of safety is the most important because it allows for the best management and treatment of patients. This will guide the hospital’s focus toward the best protocols and policies which will reduce patient harm and errors. Each policy and protocol is specifically designed for each individual facility. Medication Management is the focus area in which I chose to discuss the existing compliance of the organization. The Joint Commission’s ethics for medication management address the critical processes involved and support compliance with the National Patient Safety Goals. “The medication management standards are geared to allow assessment of the organization’s eight essential medication...
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