Aft2 Task 1

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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. 1. Joint Commission Standard MM.01.01.01 The first standard reviewed for compliance was MM.01.01.01 which determines if a hospital medication management processes are planned and coordinated among the various disciplines and services to maintain an environment of quality and safety. Furthermore, there must be written documentation in place to demonstrate compliance (Joint Commission, 20015). Compliance Status: The above standard has been met as observed by the evaluation of the Patient Specific Information policy. There is a written policy in place that documents the very specific patient information that should be accessible to those individuals responsible for the managing a patient’s medication. It further documents if the accessibility of patient’s information during an emergency situation. Plan for Compliance: For the upcoming commission visit, there are no corrective action plans needed for this area of the Joint

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