Running head: ACCREDITATION AUDIT- TASK 4
COMPLAINCE STATUS
Joint Commission clearly explained that a Periodic Performance Review is as an assessment tool designed to help in assisting the healthcare organization contributes greatly in the improvement and monitoring performance all through the year. The periodic performance focuses more on the measures that has to do with patients safety and care and at same time given the facility for unremitting standards fulfillment. NCH is 100% compliance with most standards of Joint Commission in the following area; Emergency Management, Human resources, Infection Prevention and Control, Performance Improvement, Right and Responsibilities of the Individuals, Transplant Safety. During the inspection
In creating awareness of the forbidden abbreviation, there should be a post stating a list of the forbidden abbreviation in the nursing station where it will be very visible for the staffs to view especially where the charts is placed. There should
Running head: ACCREDITATION AUDIT- TASK 4 be a training and education for the staffs, regarding the approved abbreviation by the Joint Commission. Furthermore, staffs should sign and date the patients chart after documentation.
Another standard that is not compliance with the Joint Commission standard is the pain assessment audit. The units focused on the ED, 3D, and PACU for this particular audit. When it comes to emergency department, it is seen as the minimal compliant all year round for pain assessment. This could be because of the urgency and life-threatening situation in which pain assessment might not be considered as a major priority. There should not be any reason for neglecting pain assessment because it is one of the accreditation requirements. Every assessment needs documentation in the patients record care file. All Nurse Managers of every department is in position to carry out and execute a plan based on the exact department level of care.
Safety is a primary focus in joint commission. At NCH, safety is handled as one of the most important, and its policies and procedures are often reviewed to certify that the hospital is 100%compliance with the Joint