Raft Task 1

519 Words3 Pages
Tia Henry
Western Governors University
Executive Summary for Joint Commission Standards Compliance
RAFT Task 1

Executive Summary:
Nightingale Community Hospital is a 180 bed, acute care hospital that provides compassionate, cost effective services, which has helped them gain recognition for being a leader in the health care field. The hospital values safety, community, teamwork and accountability. The hospital's vision is to be the hospital of choice and the hospital's mission is to establish a healing environment. Nightingale Community Hospital has a consistent goal to experience healthcare excellence.

I have chosen the priority focus area of Infection Control to discuss regarding current compliance standards of our hospital. The focus will be on the standards which failed to meet 100% compliance with the Joint Commission Accreditation. With a proper infection control plan, the hospital will experience harm reduction, resulting in an increase in patient satisfaction.

Areas to Monitor
One area of focus will be to reduce the risk of health care associated infections through proper hand hygiene. Over the last 3 years, hand hygiene compliance has increased from 46% to 92%. When comparing the most recent data from last year regarding hand hygiene compliance, nursing has maintained a 92% compliance rate, ancillary has maintained a 96% compliance rate and Physician’s have increased by 3%, now having a 94% compliance rate. Our goal as a hospital is 100% compliance rate, but we have identified a few problem areas that are preventing us from reaching our goal, hospital wide. These areas include: * How easily accessible is alcohol foam/gel sanitizer for employees. * Placing visible hand hygiene guidelines and reminders, in areas commonly visited by employees. For example, staff break rooms, bathrooms, nursing stations, etc. * Having an

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