Accreditation Audit Task 4

In: Business and Management

Submitted By Vivienneike
Words 3108
Pages 13
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 to enable the hospital be in full compliance with Joint Commission standard. There are some discrepancies that has to be looked into and resolve to enable NCH maintain the standard compliance with the Joint Commission. Instead of looking into problems found in each unit, there are trends affecting the hospital's patient care standard of complying with Joint Commission standard. To prevent…...

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