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Raft Accreditation Audit Case Study Task I

In: Business and Management

Submitted By hamcom2
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Executive Summary of Accreditation Audit
June 2012

I prepared and reviewed an accreditation audit for Nightingale Community Hospital to organize and ensure compliance with Joint Commission standards for our hospital. We are preparing for a site visit that should occur within the next 13 months. I have reviewed the current compliance status of our hospital and will explain our corrective action plan that will ensure compliance with the Joint Commission standards for the focus area of communication.

An accreditation audit was performed by Carl Anderson, Director of Quality. We were only in 100% compliance in December throughout the year in one of the priority focus areas of the Joint Commission standard: Communication; Standard: UP.01.03.01; A time out is performed before the procedure. See chart below:

This is the universal protocol for preventing wrong site, wrong procedure, and wrong Patient Surgeries. In evaluating this, I must review all standards that go hand in hand with the time-out standard; per Nightingale Community Hospital policy, Site Identification and Verification (Universal Protocol). I will address the elements of performance for all three: UP.01.01.01; Conduct a preprocedure verification process. UP.01.02.01; Mark the procedure site, and UP.01.03.01; A time-out is performed before the procedure.
I will then address the items that are not addressed in Nightingale's policy in my corrective action plan and add any updates.

(Commission, 2012) Standard UP.01.01.01; Conduct a preprocedure verification process to improve the accuracy of patient identification. This is a preprocedure process to verify the correct procedure, for the correct patient, at the correct site. This is met by using at least two patient identifiers when providing care, treatment and services. Acceptable identifiers are; patient's name, birth date, phone number, ID…...

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