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Joint Commission Standards

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Submitted By akabour
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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: i. Delay in delivering samples to the laboratory due to lack of personals ii. Lack of appropriate education about the dangers of some critical results in the mind of laboratory staff, specifically after hours. iii. In radiology departments: most of delays related to delay in reading X. rays or scans by radiologist especially after hours. iv. Delay in receiving the critical results by the care

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