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Accreditation Audit Task 4

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Accreditation Audit Task 4
Accreditation Audit-AFT Task 4
Western Governors University

Discuss the current compliance status of the healthcare facility.

Nightingale Community Hospital (NCH); a 180-bed, acute care, not for profit organization provides services in critical and emergency care, Oncology, cardiology, general medical and surgical services and neuroscience, vascular, level II nursery units amongst a few others. Providing these services Nightingale has held a commitment of safety, community, teamwork, and accountability. These four values have kept Nightingale compliant in several accreditation functions required by the Joint Commission.
Audits, interviews, observance and chart reviews; the Director of Accreditation has found that NCH has met accreditation standards in performance improvements (PI), rights and responsibilities of the individual (RI), transplant safety (TS), emergency management (EM), infection control (IC), and human resource (HR). Looking to the upcoming accreditation audit NCH has created effective plans in emergency operations, prevention and control, qualifications set for the hospital and staff, adequate data …show more content…
3E-Oncology had a previous average of 5.57 falls per 1000 patient days; average falls with injury per 1000 patient days was 0.89, with nosocomial pressure ulcer rate of 2.76%. Conducting root cause analysis revealed there were no direct trends related to the clinical indicators and the human resource indicators (nursing care hours and overtime). With no evident trending reports and realizing that these numbers still exceeded linear measurements; 3E took a vase approach to decreases these numbers by focusing on additional training and
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