WGU AFT Course
Raft Task 4
Accreditation Compliance Audit
2016
A Nightingale Community Hospital (NCH) is getting ready for an Accreditation Compliance Audit for the organization. As a Director, it is my position to determine whether they are ready and fully compliant before the audit is submitted for certification. To do this properly it is appropriate to perform a self-evaluation using a periodic performance review (PPR) which is a set of standards applicable to most healthcare organizations. The Joint Commission conducts either biannual or triennial surveys to audit the hospital performance. NCH is currently preparing for their biannual Audit.
A1. The current service structure of the hospital consists of Critical care, Oncology, General Medicine, Surgical services, Cardiology, Neurology, Pediatrics, and Emergency Services. According to the reviews, charts, audits, and staff reviews provided to me, I find the hospital to currently be compliant and accurate in their performance standards in the areas of Performance Improvement, Rights and Responsibilities, Transplant Safety, Emergency Service Management, Infection Control, and the Human Resources Department. In the above mentioned areas, the hospital is credible and ready for a survey inspection.
A2. Although they have been found in compliance in these areas, they have been found to be non-compliant in several other areas that need to be amended, fixed, and implemented. The following areas need immediate attention:
1. Nursing Leadership
2. Provision of Care, Treatment of Services
3. Information Management
4. Life Safety (Fire safety)
5. Medication Management
6. National Patient Safety Goals/ Universal Protocol
7. Environment of Care Services
8. Record of Care
9. Medical Staff
Nursing Leadership shows deficiency and non-compliance in the areas of documentation and timeliness which affects staff morale. Nurse Managers are expected to provide routine oversight of making sure...