Audit Task 4

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Accreditation Audit- Task 4
A1.
Nightingale Community Hospital uses a form of self review in order to prepare for the joint Commission’s audit. They look into areas that their hospital is both compliant and non compliant in order to get the best picture of how they’re doing as a whole (all units within the hospital). Each hospital is held accountable for 18 accreditation requirements (Commission, 2013). Through this review, Nightingale Community Hospital showed to be compliant in the following: Emergency Management, Right and Responsibilities of the Individual, Transplant Safety, Human Resources, Infection Prevention and Control, Waived Testing and Performance Improvement. They also showed through this review to be Non-Compliant in Environmental Care, Leadership, Record of Care, Treatment and Services, Life Safety, Nursing, Medication Management, Medical Staff, and National Patient Safety Goals. The results of the review process showed that there was a definite need for education to be reinforced and that they needed to start implementing audits. The review showed fire hazards and safety issues due to the fact that there was an increased amount of clutter in the halls. Nurses were uncomfortable with the appropriate way to take and give proper verbal orders, how to use the diverse amount of orders that are received on a daily basis and which abbreviations are appropriate to use and which are prohibited when documenting. To deal with the problems appropriate action will be set up according to the needs of each specific unit and their areas of non-compliance. The action plans will be put in place and then followed up on to see if they are achieving their intended goal. In order to hold up to Joint Commission’s standards and to stay a hospital of choice it is inevitable that action plans are implemented to address areas that don’t make the cut. Reviewing the
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