Accreditation Audit (AFT2) Task 4
Facilitate an organizations continuous accreditation compliance process

Compliance Status

The period performance review (PPR) conducted by the Joint Commission has identified several areas of focus for Nightingale Community Hospital (the Hospital). The Hospital has also made great strides in improvements in several areas over the past two years. The following areas are in total compliance with the Joint Commission standards; Emergency Management, Human Resources, Performance Improvement, Rights and Responsibilities of the Individual, and Transplant Safety (The Joint Commission 2014).
The Periodic Performance Review (PPR) provides details of the areas where the Hospital is out of compliance. The table below identifies the standard with a brief synopsis of the current state.
Standard
Violation Synopsis
Environmental Care (EC)
Smoke wall penetration noted several times
Annual test of medical gasses master alarm panel was not completed per policy
Fire drill frequency does not meet standards
Leadership (LD)
Staffing patterns.
Nurse to patient ratio.
Low morale among nursing staff.
Life Safety (LS)
Clutter in hallways noted for multiple nursing units
Fire extinguisher blocked noted for multiple nursing unit
Interim Life Safety Measures (ILSM) not carried out during 3 construction projects
Gift Shop clearance from speakers was not 18”
National Patient Safety Guidelines (NPSG)
Unlabeled syringes in OR and Cath Lab - propofol
Unlabeled basins
Prelabeled syringes in cataract packs from external supplier
Universal Protocol (UP) - Prohibited abbreviations found over multiple nursing units for different documents
UP -Surgical site not marked – sentinel event
UP - Surgical side not marked – sentinel event
UP – prohibited abbreviations found in multiple note types over several nursing units
Medication Management (MM)
Unlabeled syringes in OR and Cath Lab - propofol
Nurse unable to articulate how range dose policy is executed
Provision of Care, Treatment, and Services (PC)
Day of Procedure Reassessment missing in numerous cases, over numerous nursing units
Lack of pre sedation American Society of Anesthesiologists (ASA)
Pain and assessment consistently missing in ED records
Record of Care, Treatment, and Services (RC)
Verbal orders not authenticated within 48 hours noted several times over multiple nursing units.

Nursing (NR)
One specific nursing unit consistently does not document in a timely manner
Medical Staff (MS)
Ongoing Professional Practice Evaluations do not meet standards

Specific to the PPR Report findings, columns labeled Accreditation Function and Reference Standard, Infection Control (IC) is not listed as an area with a negative finding, which generally means the Hospital is within the compliance standard. However, I have included them in the ‘out of compliance’ report based on the staffing effectiveness report. In this report we see pressure ulcers prevalence on 3-East Oncology along with ventilator associated pneumonia in the Intensive Care Unit. Infections control is an area that should be considered for monitoring and improvement by the Hospital.
Non Compliant trends

Close review of the data identifies several trends within the Hospital. Many of which are non complaint trends found in the historical data collected from the Hospital. I will briefly review the non compliant patterns present in the PPR.
Historical fire drill data shows a pattern of the third shirt missing participation in two of the quarterly fire drills.
In the Endoscopy Department the Oxygen saturation monitored at 30 minutes shows a pattern of poor performance.
The Pain Assessment Audit for the Emergency Department (ED) shows a pattern of substandard performance. The Pain Reassessment Audit shows a downward trend in the ED, with as much as a forty percent drop in carrying out the pain assessment in the ED.
Prohibited Abbreviations for the two most frequently used (“cc” and “qd”) are still evident in