Accreditation Audit Essay Sample

1. Conformity Status
Following regulations and ordinances is of import for establishments and any type of constitution to keep organisation and most significantly provide safety for those involved. For the organisation and safety of everyone involved. it is of import to follow with peculiar standards.

Hospitals are one of the many organisations that must follow with ordinances to maintain patients and staff safe and every bit good as maintain the quality of attention. Ideally. a good attention system for patients includes medical professionals every bit good as friends and household to congratulate each other in supplying for patient demands. Because patients require attention from medical professions in infirmaries. there are commissariats that the infirmary must follow. “Compliance means conforming to a regulation. such as a specification. policy. criterion or jurisprudence. Regulatory conformity describes the end that corporations or public bureaus aspire to in their attempts to guarantee that forces are cognizant of and take stairss to follow with relevant Torahs and ordinances ( Conformity and Regulatory Compliance. 2013 ) ” .

For this ground there are footings of conformity that infirmaries must adhere to. The Joint Commission Handbook serves as a agency of ordinance and conformity for infirmaries and other such installations. There are four classs that the Joint Commission focuses on during the accreditation audits for a infirmary: Information Management which involves the efficient direction of wellness information and truth. Medication Management affecting labeling and asepsis. Communication affecting confirmation. and Infection Control to minimise spread and infection.

We will be executing an accreditation audit to corroborate that conformity criterions are met for Nightingale Community Hospital. This accreditation audit will concentrate on Nightingale Hospital and the care of communicating within the infirmary. Communication is the activity of conveying information through the exchange of ideas. messages. or information. as by address. visuals. signals. composing. or behaviour. ( Communication ) ” . We will be carry oning an executive sum-up to chart the current conformity criterions based on the Joint Commission Handbook.

Nightingale Community Hospital has a sum-up of current conformity informations for their peculiar infirmary. There are a few precedence focus countries that we will be concentrating on for Nightingale Hospital based on the information provided for an accreditation audit. The first precedence focal point country under communicating conformity criterions that Nightingale Hospital is concentrating on is the behavior of pre-procedure confirmation procedure.

Based on the joint committee enchiridion. there are a few elements of public presentation that Nightingale Community Hospital must run into to be in conformity. The first criterion under communicating division is. carry oning a pre-procedure confirmation procedure for the patient. There are elements of public presentation that must be met under this criterion for conformity. The first is executing a pre-procedure confirmation to place the right process. patient. and site. This component of public presentation is met by Nightingale under the Hospital Universal Protocol Policy and a pre-procedure press release for the confirmation of patient on an armband. The following two elements of public presentation are the designation of points that must be on manus during any process and fiting the points that need to be available to the patient. Based on the information that was given. Nightingale Community Hospital does non run into these elements of public presentation under this criterion for communicating.

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The following criterion for communicating is taging the process site. There are five elements of public presentation that must be met for this criterion. The first is placing processs and scratch site. peculiarly for spinal processs. The 2nd slug is taging the site before a process begins. The 3rd is holding the process site market by a accredited practician. The 4th is doing certain the pronounced site is non obscure and consistent throughout Nightingale Hospital. All of these elements of public presentation are met in the Universal Protocol Policy. However. documenting the completion of a “time out” is met by the Universal Protocol Policy but besides has the added benefit of being stated in the Pre-procedure press release. Upon conductivity the accreditation audit for taging the process sites. Nightingale Community Hospital has policies in topographic point to do certain they are being met.

The concluding criterion under communicating is the public presentation of a “time out” before a process. There are besides elements of public presentation that must be met to be in conformity for this criterion. The first is carry oning a “time out” before every process. This is met by the Universal Protocol Policy. The Universal Protocol Policy besides meets the following slug point of standardising “time out” for Nightingale Hospital and holding them started by an elective squad member with the engagement of squad members. The 3rd component of public presentation is executing a “time out“ between a alteration of people executing a process on a patient.

This is unluckily non met by any protocol in the information provided by Nightingale Hospital. Having squad members agree the right patient individuality. the right site. and the right process to be done on a patient is the following component of public presentation. The concluding component of public presentation is the certification of “time outs” . Though there are no policies bases on the information given from Nightingale Hospital of “time outs” . there is a graphical analysis of “time outs” infirmary broad bespeaking the conformity per centum for each month during the twelvemonth. The graph indicates that for the full twelvemonth. December was the lone month where required “time outs” were performed one hundred per centum of the clip.

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2. Plan for Conformity
We will be implementing a disciplinary action program to convey Nightingale Community Hospital into conformity for communicating.

The first criterion in communicating has several countries of public presentation. Since the first component of public presentation is met. it is imperative to originate a program for the 2nd and 3rd elements of public presentation. To run into the 2nd country of conformity. Nightingale Hospital will necessitate to hold a system in topographic point to place the points needed for any type of process. We will necessitate to make a standardised list including relevant certification. labelled trials consequences. and needed equipment needed for the specific processs ( i. e. blood merchandises ) . This standardised list must besides hold a subdivision delegated to fiting the points to the patient in order meet the last component of public presentation for the pre-procedure confirmation criterion. Implementing these standardized lists will see that this criterion is met.

The following criterion to be met is taging the process site. Nightingale
Community Hospital has routines in topographic point for all of the elements of public presentation for this criterion hence. there will non be a disciplinary action program implemented for this criterion.

The concluding criterion is executing a clip out before every process. There are five elements of public presentation in this criterion which include: carry oning a “time out” before saying a process. doing certain “time outs” are standardized and initiated by a member of the squad with engagement from the full squad. doing certain “time outs” are performed during a alteration in individual that are executing the processs and eventually. the certification of “time outs” . Three of these elements of public presentation are met for this criterion but. the act of executing “time outs” during alterations of the individual executing the processs does non happen based on the grounds of Nightingale Community Hospital.

To rectify the deficiency of this public presentation component. we will be implementing a disciplinary action program to include this in the policy. Since holding a alteration of individual does non name for a pre-procedure press release. a professional get downing a new process will be required to make full a different process press release than prior to get downing the process. The certification of these clip outs is besides non indicated anyplace within Nightingale Community Hospitals policy. There is nevertheless a graphical analysis of the conformity per centum for the twelvemonth bespeaking that there is a method of entering “time outs ( Figure 1 ) . A disciplinary action program for this would be for Nightingale Community Hospital to implement this into the Universal Protocol Policy and the pre-procedure press release to extinguish any disagreements. This will guarantee that conformity criterions are met for all countries.

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3. Justification
Nightingale Community Hospital has provided informations on old conformity criterions. Figure 1 shows the per centum of countries for betterment on identifying and labeling specimens. For the past twelvemonth. Nightingale Hospital has had 18 per centum chance for bettering criterions and for the current twelvemonth there is a 42 chance per centum for betterment. This means that between the past twelvemonth and the current twelvemonth. there were more disagreements reported. This provides significant support and ground to implement a disciplinary program for a pre-procedure confirmation procedure in order to run into all of the elements of public presentation.

Figure 1: Opportunities for Improvement

The 3rd criterion of executing clip outs. has three elements of public presentation that deficiency conformity criterions. Figure 2 shows the per centum of naming “time outs” every month for the twelvemonth. Based on the information. December was the lone month that was one hundred per centum in conformity for the twelvemonth which means there needs to be a system in topographic point to extinguish disagreements and do certain clip outs are ever called.

Figure 2: Hospital Wide Time Outs
Figure 3 shows per centum of verbal read dorsums to see information is right. This graph shows that merely one section infirmary broad has met one hundred per centum conformity for verbal orders and read dorsums. Because merely one section was in conformity. it supports the grounds that a disciplinary action program is needed to guarantee that information is right by agencies of verbal read dorsums.

Figure 4 shows the per centum of describing critical consequences of certification. The highest per centum of conformity is 82 which means that there is room for betterment. By holding figure 2. 3. and 4 in one hundred per centum conformity. this will guarantee that the” clip out” criterion be met fulfilled.

Making certain establishments are in conformity with ordinances will assist see the safety of everyone involved.


Communication. ( n. d. ) . Retrieved from Wikipedia: hypertext transfer protocol: //en. wikipedia. org/wiki/Communication

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( 2013. 2 ) . Conformity and Regulatory Compliance. ( L. J. Gumm. Interviewee )