Accreditation Audit Task 1

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Accreditation Audit Task 1 2-13-2012 Nightingale Community Hospital (NCH) has developed procedures to be compliant with the Joint Commission (JC), and while most Priority Focus areas have been addressed there are some gaps needing attention. Each Priority Focus will be discussed here, detailing successes as well as areas for improvement. Joint Commission Standard: UP.01.01.01 Conduct a preprocedure verification process. NCH does provide a detailed, step-by-step protocol to verify the patient and procedure prior to operation. The protocol spells out exactly when these steps must be followed, such as when the patient is transferred to another caregiver (not solely before surgery). NHC is in compliance on this section. The next part of JC requirements is to “Identify the items that must be available for the procedure and use a standardized list to verify their ability”. NHC is not obviously compliant with this standard; the items are mentioned in the policy but not clearly defined. This will need to be corrected in order to be fully compliant with JC. The last section of this standard is to match these items that are to be available in the procedure area to the patient. This can be incorporated into the corrected for the previous standard section. Joint Commission Standard: UP.01.02.02: Mark the procedure site NCH has a substantive procedure on how and when to mark the procedure site; however it is not fully compliant. The hospital’s policy does follow JC while describing the situations requiring marking but does not require the person actually drawing the mark to be a physician. JC clearly states that the procedure site is marked by a licensed independent practitioner who will be present during the procedure and is accountable for the results. NCH’s policy is for the patient themselves to make the mark. The patient should definitely be involved, but

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