Accreditation Audit Sample Essay

Accreditation Audit Sample Essay

The Joint Commission provides guidelines which the Nightingale Community Hospital is supposed to follow. The Standard Assessment identified certain areas of compliance and other areas of non-compliance with the relevant provisions of the Joint Commissions standards as highlighted in this report (Joint Commission International, 2017). Accreditation Audit Sample Essay

Compliance Status

The Joint Commission provides standard of compliance such as the Safety standard(LS), Environment of Care standard (EC), Information Management standards (IM), Medical Staff standards (MS), Nursing standards (NR), National Patient Safety Goals standards (NPSG), Provision of Care, Treatment, and Services standards (PC), Leadership standards (LD), Medication Management standards (MM), and Record of Care, Treatment, and Services standards (RC) (Joint Commission International, 2017). A healthcare provider is required to comply with all these standards in order to be granted a clean bill of health in the provisions of healthcare services.

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However, the standard assessment of the hospital reveals that it is in compliance with the requirements of the Accreditation Participation standards of the Joint Commissions that qualifies it to take part in the accreditation process and subsequently qualifying for accreditation. Among the standards that the hospital has complied with is the Emergency Management standard which is in line with the regulations of the Joint Commission standards. The standards of the facility clearly demonstrate an institution that is well prepared to handle any form of disaster and emergency in the course of its operations (Joint Commission International, 2017).  The facility has a hazard vulnerability assessment report that outlines the potential threats and hazards, as well as the effective action, plans to mitigate their impacts.

Another area of compliance with the Joint Commissions standards is the Human Resources standards. The hospital has an effective process of verifying the qualifications of its staff, an effective method of staff orientation, training, appraisal, and evaluation. In addition, the Infection Control standards of the health facility are in compliance with the requirements of the Joint Commission Standards (Forasassi & Meaume, 2015). The noncompliance is due to the fact that it has put in place measures to monitor, evaluate, and analyzes infection controls through a trend identification to minimize new infections.

Another compliance to the Joint Commissions standards noted in the Nightingale Community Hospital is the Performance Improvement. The facility has put in place improvement priorities with timeline son how to ensure continuous improvement in its operations. Using data collected from various departments, the facility evaluates the actions plans that would yield better outcomes in future (Forasassi & Meaume, 2015). In addition, the facility is in compliance with the Joint Commissions standards on Rights and Responsibilities of the Individual because it recognizes the rights patients to privacy, autonomy, and confidentiality.

Through effective patient interaction, Nightingale Community Hospital follows the right procedures and policies to facilitate safe organ and tissue donation in line with the Joint Commission’s safety standards on organ Transplant (Joint Commission International, 2017). Its waived testing is also in compliance with the joint commission’s policies and procedures because its competent staff performs waived testing in compliance with the quality control standards. Accreditation Audit Sample Essay

Non-Compliance Status

The compliance rate of Nightingale Community Hospital was an average of 75% without any sign of significant improvement.  Consequently, there were major instance of noncompliance in areas such as Safety (LS), Environment of Care (EC), Information Management (IM), Medical Staff (MS), Nursing (NR), National Patient Safety Goals (NPSG), Provision of Care, Treatment, and Services (PC), Leadership (LD), Medication Management (MM), and Record of Care, Treatment, and Services (RC) were not met.

Noncompliant Trends

The Focused Standard Assessment of Nightingale Community Hospital revealed evident trends that may lead to non-compliance with the Joint Commission standards for patient care. It was established that the facility was in violation of the Environment of Care standard of the Joint Commissions as illustrated by the penetration in noted in its firewalls. Among these trends is the multiple penetration in the firewall noticed in the environment of care section in addition, the audit revealed that the fire drills were conducted in violation of the Joint Commission regulations that require the facility to conduct a single drill per shift per quarter (Vlaeyen, Coussement, Leysens, et al., 2015). In addition, the facility violated the Joint Commissions standards on Information Management as illustrated by the use of abbreviations note approved by the Joint Commission.

The trend of non-compliance with the Joint Commissions standards for NR and LD was attributed to the fact that nurses were understaffed and too busy to document timely. In addition, the signs of cluttered hallways at the facility were signs of non-compliance with the Joint Commission’s LS standard.  Besides, there were no signs of walkthrough activities in the area where fire drills are conducted to prevent cluttering and ensure intact firewalls. On the other hand, the facility’s non-compliance with MM standards was indicated by nurses’ inability to adhere to the range does policy (Vlaeyen, Coussement, Leysens, et al., 2015).

Instances of noncompliance to the MS standard were indicated by the OPPE process which failed to meet requirements. The fact that the facility allowed tow incidence of wrong procedure in labeling is an indicator for noncompliance with the Joint Commission’s NPSG standard. The facility was also in noncompliance with the Joint commission’s standards on PC since its reassessment process was not conducted regularly. In addition, the failure to authenticate verbal orders within 48 hours illustrated non-compliance with the RC standard of the Joint Commissions.

Staffing Patterns

The staffing pattern at Nightingale community hospital has three units which were subjected to the evaluation to determine nosocomial pressure ulcers, nursing hours relating to falls and ventilator-associated pneumonia.  At the 3 East-Oncology, it was noted that the staffing at this unit was committed to improving service delivery so that the falls and pressure ulcers are reduced (Forasassi & Meaume, 2015). The nursing staff in this unit are engaged and always take part in the NICHE training to acquire better knowledge and skills to provide improved care for older adults.  The skin care representative in this unit is instrumental in providing support to the pressure ulcer initiative. There was also a consisted pattern in the staffing hours with no negative trends in respect to nosocomial pressure ulcers, staffing, and falls.

The staffing at the 3-East Oncology unit of the facility revealed a different situation with an increase in falls and nosocomial pressure ulcers in the recent pasts. The compliance audit revealed an inconsistency in the working schedule and nursing staff hours with more cases of nurses working for longer hours (Forasassi & Meaume, 2015). Surprisingly, the frequency of falls and nosocomial pressure ulcers occur increased despite the long working hours.

The staffing at the Intensive Care Unit (ICU) of the facility recorded an increase in the rate fall leading to the implementation of an improvement plan to decrease falls.  The first quarter recorded the highest number of falls showing that the improvement plan was effective and the full engagement of the staff of this unit who were committed in the fall prevention programs and investigations of a case of fall (Vlaeyen, Coussement, Leysens, et al., 2015). They also shared the data relating to hospital falls with other care providers to increase collaboration towards reducing future cases of fall. Moreover, the nursing staff hours at this unit was consistent. Clearly indicating an insignificant correlation between the increased cases of fall to the nursing care hours. Accreditation Audit Sample Essay

Staffing Plan

            With the status of compliance, trends that may lead to non-compliance, and instances of inadequate nursing staffing at Nightingale Community Hospital, there is a need for the hospital administrators, insurers, accrediting agencies, and regulators to take action and improve the nursing through an effective nursing plan. This nursing plan should focus on ensuring that there is an adequate nursing staff available to protect patients and improve the quality of care at the facility. There should be a greater number of nursing hours dedicated to the healthcare facility in all the three units to enhance better care for hospitalized patients. Besides, the staffing action plan will help reduce the cases of falls and nosocomial pressure ulcers at the 4-East Unit is a medical/surgical unit of Nightingale Community Hospital upon increasing the nursing hours increase (Forasassi & Meaume, 2015).

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The staffing plan should also provide for an increase in nurse engagement at the 4-East unit to ensure that all the nurses in the unit are involved in the fall prevention team, and attend training specific for fall prevention. The staffing plan should also provide a framework of disseminating information to other nurse colleagues in respect to the required training and meetings. The nurse administrator should, therefore, be in charge of providing information in the rate of attendance for the team participation and training for to the Quality Assurance Committee four times in a year (Cho, Lee, Kim, et al., 2016). The skin care sections should have a nurse representative to share knowledge and expertise with other nurses on how to decrease pressure ulcers among patients.

Finally, the management of Nightingale Community Hospital will increase the number of LPN and RN I to decrease cases of pressure ulcers and fall among patients. Consequently, a single LPN will be scheduled per shift lasting for 8 hours in the 4-East unit. This staffing plan will decrease fatigue among nurses, thus promoting patient safety.

Sunday Monday Tuesday Wednesday Thursday Friday Saturday
RN I PERMANENT 8:30-17:45 8:30-17:45 8:30-17:45 8:30-17:45 8:30-17:45 8:30-17:45
RN  I PERMANENT 8:30-17:45 8:30-17:45 8:30-17:45 8:30-17:45 8:30-17:45 8:30-17:45
RN  I PERMANENT 8:30-17:45 8:30-17:45 8:30-17:45 8:30-17:45 8:30-17:45
RN  I PERMANENT 8:30-17:45 8:30-17:45 8:30-17:45 8:30-17:45 8:30-17:45
RN VI PERMANENT 8:30-17:45 8:30-17:45 8:30-17:45
LPN  VI PERMANENT 8:30-17:45 8:30-17:45 8:30-17:45
RN  I PERMANENT 17:45-23:45 17:45-23:45 17:45-23:45 17:45-23:45 17:45-23:45
RN  I PERMANENT 17:45-23:45 17:45-23:45 17:45-23:45 17:45-23:45 17:45-23:45
RN  I PERMANENT 17:45-23:45 17:45-23:45 17:45-23:45 17:45-23:45 17:45-23:45
RN  VIII PERMANENT 17:45-23:45 17:45-23:45 17:45-23:45 17:45-23:45
RN VI PERMANENT 17:45-23:45 17:45-23:45 17:45-23:45
LPN  I PERMANENT 17:45-23:45 17:45-23:45 17:45-23:45 17:45-23:45 17:45-23:45
RN  VI PERMANENT 17:45-23:45 23:45-8:30 23:45-8:30
RN  I PERMANENT 23:45-8:30 23:45-8:30 23:45-8:30 23:45-8:30 23:45-8:30
RN  I 23:45-8:30 23:45-8:30 23:45-8:30 23:45-8:30 23:45-8:30
RN  I 23:45-8:30 23:45-8:30 23:45-8:30 23:45-8:30 23:45-8:30
RN  VI PERMANENT 23:45-8:30 23:45-8:30 23:45-8:30
RN . 6 PERMANENT 23:45-8:30 23:45-8:30 23:45-8:30
LPN  I 23:45-8:30 23:45-8:30 23:45-8:30 23:45-8:30 23:45-8:30

Table 1: Table illustrating Staffing plan and pattern for the 4-East Unit is a medical/surgical unit of Nightingale Community Hospital Accreditation Audit Sample Essay

References

Cho, E., Lee, N. J., Kim, E. Y., Kim, S., Lee, K., Park, K. O., & Sung, Y. H. (2016). Nurse staffing level and overtime associated with patient safety, quality of care, and care left undone in hospitals: a cross-sectional study. International journal of nursing studies60, 263-271.

Forasassi, C., & Meaume, S. (2015). Managing pressure ulcers in palliative care in geriatric units. Soins; la revue de reference infirmiere, (792), 35-38.

Joint Commission International (2017). Joint Commission on Accreditation of Healthcare Organizations. (2005). Hospital accreditation standards: standards, intents: HAS. Joint Commission on.

Vlaeyen, E., Coussement, J., Leysens, G., Van der Elst, E., Delbaere, K., Cambier, D., … & Dejaeger, E. (2015). Characteristics and effectiveness of fall prevention programs in nursing homes: A systematic review and meta‐analysis of randomized controlled trials. Journal of the American Geriatrics Society63(2), 211-221.

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Accreditation Audit Sample Essay

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