AFT2 Accreditation Audit – Medication Management Western Governors University EXECUTIVE SUMMARY The Joint Commission sets standards for quality and safety in health care with each standard having associated criteria used to determine a hospital’s compliance status. Nightingale Community Hospital (NCH) will be fully engaged in activities with the Joint Commission within 13 months to determine our compliance statuses with three of the standards that governs medication management. As a precautionary measure, a vigorous evaluation of the medication management policies and practices was undertaken to assure that NCH remains in compliance and will be able to pass the upcoming accreditation audit. More importantly, this ongoing process is vital towards our core value of improving the quality and safety of our patients. The following is the result of the evaluation of NCH’s medication management and medication safety program.
Joint Commission has laid out a strategic and detailed set of expectations that hospitals and other healthcare organizations can use to ensure they are in compliance with health laws. At Nightingale we seem to be in compliance with a number of these standards. According to a recent periodic performance review we are in compliance with the Joint Commission standards in the Emergency Management requirement section. The EM develops a plan in case the facility has an emergency that includes the planning of activities of hospital administrators and leaders. This plan should include details that would identify what an emergency is, how it would be communicated to the staff, and what arrangements will be made for the facility.
This data is processed and statistically analyzed to determine ways in which the hospital can improve patient care and patient outcomes. “Statisticians often divide their subject into two major branches: descriptive statistics and inferential statistics,” (Bennett, Briggs, & Triola, 2009, p. 7). One of the ways data is collected and used is descriptive statistics. Descriptive statistics “describes raw data in the form of graphics and sample statistics,” (Bennett et al., 2009, p. 7). St. Agnes uses statistics to meet benchmark standards.
In fact, UnitedHealth Group made significant investments in research and development, technology and business process improvements – nearly $3 billion in the past five years. These investments led to changes that are improving the way care is delivered and administered across the entire industry (United Healthcare, 2013). United Healthcare continues to meet the demands of future generations with such creations such as Health4me app, MyHealthcare cost estimator, and UHC TV (UnitedHealth Group, 2012). Health4Me, that brings important health information to people on the go. Features include easy access to registered nurses, personal health benefits information, and the ability to locate nearby physicians and hospitals (United Healthcare,
7. This professor is barred by the department from this practicum. No questions will be answered or assistance given by this professor or technician or any other. There is one exception made to this rule discussed in the second section of this document. 8.
Doesn’t address all phases of the nursing process. Does not include at least 5 interventions with rationale. Does not address reportable data, labs, and referrals. | Did not submit concept map. | 2 | Safety | Follows standard precautions.
Now What ? Action is planned and carried out on the basis of what you have learned and what u propose to improve upon in future. Using the above reflective model I will now write an account of my involvement in the Cleanliness Champions Programme in my first year of clinical practice . This particular account will be specific to my involvement in the safe handling and disposal of waste and laundry in the Clinical Environment. What?
3.2 show that you have a quality culture which makes sure that processes are continuously improved 3.3 recommend relevant and realistic improvements in your systems 3.4 investigate and then report on the wider impact of your proposed changes within your organisation Contents 3.1 Design a system to manage and monitor quality standards in your chosen organisation 3.2 show that you have a quality culture which makes sure that processes are continuously improved 3.3 recommend relevant and realistic improvements in your systems 3.4 investigate and then report on the wider impact of your proposed changes within your organisation 3.1 Design a system to manage and monitor quality standards in your chosen organisation Contents 3.1 Design a system to manage and monitor quality standards in your chosen organisation 3.2 show that you have a quality culture which makes sure that processes are continuously improved 3.3 recommend relevant and realistic improvements in your systems 3.4 investigate and then report on the wider impact of your proposed changes within your
* Justification of an importance for the communication standards for NCH. Current Status NCH Communication standards compliance to 2013 Joint Commission Hospital Standards for Communication NCH current standards and protocols in place | Joint Commission(JC) Standard Number | Joint Commission Standards, retrieved from Joint Commissions on Accreditation of Healthcare Organizations (2013) | NCH Preprocedure Hand-Off form | UP.01.01.01 | Conduct a preprocedure verification process. | Overall finding: Based on the provided material, NCH preprocedure hand-off form, there appears to be a preprocedure verification process in place within the hospital. This form, however, does not have a clear division of information areas that are collected and the data provided is not completely compliant with JC to provide a full list of the required information: | 1. The NCH preprocedure hand-off form provides Y/N response to identification process but lacks an important information such as name of the patient, the patient`s identifier (e.g.
Specifically three standards that fall under the communication focus area. They are identified as standard UP.01.01.01- Conduct a preprocedural verification, standard UP.01.02.01- Mark the procedure site, and standard UP.01.03.01- A time-out is performed before the procedure. Standard UP.01.01.01 is defined as; The Universal Protocol applies to all surgical and nonsurgical invasive procedures. Evidence indicates that procedures that place the patient at the most risk include those that involve general anesthesia or deep sedation, although other procedures may also affect patient safety. Hospitals can enhance safety by correctly identifying the patient, the appropriate procedure, and the correct site of the procedure ("Joint commission e-dition,”) The universal protocol is based on the following principles: - Wrong-person, wrong-site, and