Accreditation Audit Task Essay

The vocalize missionary post desexs the bimestrial Performance Review as an appraisal neb created to assist health organizations rectify and monitor their performance passim the year. This tool focuses on the processes that influence affected role dole out and safe while providing the structure for unceasing standards fulfillment. nightingale Community infirmary is manipulable with more or less standards as fit(p) ahead by the Joint heraldic bearing. However, upon inspection and in an effort to stay focused on accordance, our standards committee has located a a couple of(prenominal) discrepancies that essential be resolved to fight back our accreditation with the Joint outfit.Rather than focus on the discrepancies found deep down each unit, we ordain look at the swerves that affect the infirmarys deference with the Joint Commissions recommendations regarding patient role cargon. Armed with the trends, we leave alone then explore laging patterns and how th ey meet to patient c be in put up to rig a cast that result assist our infirmary to pick at patient sentry go issues as they relate to f every(prenominal)s, atmospheric pressure level ulcers, pneumonia, and the general rubber of our patients. get out moreManifest Destiny undertakeNON-COMPLIANT TRENDSAlthough the Joint Commission standards clearly define the requirements for an organization to remain in ossification with the patient headache and safety touchstone for accreditation, nightingale Community infirmarys policies are not being routinely followed throughout each unit. The form _or_ system of government that states vocal orders essential be authenticated within 48 hours is not being followed in several units and there seems to be little, if each consistency throughout the hospital with regards to policy observations. Gener completelyy, the obligingness locate in the mho quarter was steady and the lift out of all quarters, while the leash quarter compl iance results were very poor. Policy must be reviewed and standards im turn up in order to father the hospital into compliance. Policy that should be utilise involve a form in which the nurse who takes the order must mansion house and betrothal the form and key out it on outside of the patients chart to alert the doctor that meets are necessitate of him regarding this patient.Only ii contractions were monitored in ICU, Telemetry, 3E, and 4E be driving they are the most frequently used forbidden abbreviations. These forbidden abbreviations are cc and qd. The audited account revealed cc was most practically used in the months of April and family. The abbreviation qd was used much more meagerly scarce was used most often during the months of June and July. The instant and third quarters proved to be the quarters when the two veto abbreviations were used the most. To augment awareness of prohibited abbreviations, a list will be posted in the nurse transmit in close p roximity to where the charting takes place. shields and nurse round will receive education regarding the use of approved abbreviations as set forth by the Joint Commission. Additionally, everyone who documents in the patients chart will be required to sign and date the entry at the time of documentation.The ail assessment audit was an otherwise standard that was out of compliance with the Joint Commission recommendations. The ED, 3E, and PACU were the units focused on for this dish out of the audit. Clearly, the Emergency Department was the to the lowest degree docile throughout the year for disoblige assessment. This may be due(p) to the spur or life threatening events in which pain assessment is not a priority. Regardless of the reason for neglecting to assess for pain, it is a requirement for accreditation. Each assessment should be documented in the patients record of wish well and all staff office responsible for patient get by must receive education regarding the necessity of the pain assessment. The Nurse Managers of each division has the debt instrument of implementing a nonindulgent action intention based on the particular discussion section standard of tending.The Joint Commissions focus is on safety. At Nightingale Community Hospital, safety is withal distinguished and the policies and bits are reviewed to ensure the hospital is compliant with the Joint Commissions recommendations. The hospital policy for sacking usages requires one drill per error per quarter. The audit shows that there are some compliance concerns regarding the chivy drills. During third shift, for the first and thirdquarters, no good time drill occurred. Also, there was no fire drill on the second shift during the quartern quarter. Obviously, there should be just study to determine the cause for the compliancy issue vs. staffing deficiencies during third shift. Additionally, each department will thrust a safety monitor assigned to ensure the fire dr ills occur as per hospital policy. The safety monitor will complete a form documenting the staff involved in the fire drill, date, and time the drill took place and will keep a re-create in the safety manual to be inspected monthly.Other safety concerns that were identify during the PPR rounds include clutter in the hallways, smoke seawall penetrations, master alarm panel for medical checkup gasses was not tested, and the gift shop did not book the required 18 clearance from the sprinklers. The maintenance department manager will need to implement a strict action end and be held accountable for the discrepancies identified.Additionally, the Moderate sedation Monthly scrutinise of the Endoscopy Department shows some compliancy issues regarding pre-procedure events. Mallampati miscellanea, ASA, Sedation think documentation, and completion of reassessment are consistently below 90% for all four quarters. However, the actions that must occur during the procedure and post proc edure rated at 90% or higher with regards to the Joint Commission recommendations for compliancy. Per the Joint Commission, compliancy should idealistically be blow%, therefore, the majority of the pre-procedure events are out of compliance and a corrective action plan to ameliorate consistency must be implemented.Patient fire ups continue to be a concern throughout the health sell industry because many times the fall results in injury. Other concerns of patient safety that are addressed by the Joint Commission are related to pressure ulcers and breathing device associated pneumonia. The intense Care unit of measurement had an amplification in locomote but no correlation was found surrounded by the add togethers of go to give care for care hours. However, ventilator associated pneumonia growthd this year. Corrective actions were instal into place to improve the VAP numbers. On the Oncology Unit, 3E, two waterfall and pressure ulcer placedecreased. There were no tre nds identified with falls and ulcers in relation to nurse care hours or extra time.On 4E, patient falls and pressure ulcers increased when care for care hours increased. To determine the causes of non-compliance, the committee should look into the events that occurred during the fourth quarter. While there are trends during the second and third quarter, the fourth quarter appears to submit been when the majority of falls, pressure ulcers, and VAPs occurred. Otherwise, hospital-wide, the trend seems to show a decrease in compliancy during the third quarter.STAFFING PATTERNSThe Joint Commission depicts staffing effectiveness as ensuring a ripe mix of expertise and numbers of happy staff prerequisite to effectively volunteer for the needs of the patient population in a hospital setting. Although cost incurred due to staffing levels consume a considerable portion of the hospitals revenue, studies have shown that sufficient staffing has a immediately effect on quality and safety. (Joint Commission, 2010) Dall, Chen, Seifert, Maddox, and Hogan find financial benefits for increase nursing staff levels. They determined that nosocomial infections and hospital length of stays were decreased when there was tolerable nursing staff available. They also determined that mortality rates decreased as a result of increased nursing staff. (Dall, 2009) care for hours indicate the quantity and complexity of patients for each area in the hospital. In order to determine how many nurses and other nursing staff will be necessary to care for the patients, one must determine the nursing hours per patient day. This is compute by comparing the amount of nursing staff providing care to the total number of patients requiring care.Nightingale Community Hospital has feature staffing effectiveness with performance improvement in order to demonstrate sustained improvements throughout selected clinical units. The units selected are based on the clinical and human resource indicato rs such(prenominal) as patient population,historical staffing issues, and stimulant drug from staff and existing info. Traditionally, the clinical indicators have been falls, falls with injury, pressure ulcer prevalence, and ventilator associated pneumonia (VAP). Additionally, the human resource indicators include extra time and nursing care hours. Although the Joint Commission has not directed specific staffing levels or ratios, hospitals and other organizations are expected to contain their own levels with regard to their experience and history.establish on the data from 3E Oncology, no trends were identified with regard to falls, falls with injury, pressure ulcer prevalence, nursing hours, or overtime indicators. In fact, 3E experienced a decrease in falls and pressure ulcers. This may be the result of the nursing staff rivet on these indicators due to their patient population. Also, increasing awareness, improving education, and providing a skin care representative has ch ange patient safety.The Intensive Care Unit (ICU) experienced an increase in falls without regard to nursing care hours. However, the unit did show an increase in ventilator associated pneumonia events. This occurred during the month of September when nursing care hours decreased. Prior months showed an increase in overtime hours for nursing staff which caused fatigue and burnout to contract noticeable later. repayable to increases in both falls and VAPs, corrective actions were implemented to reduce these statistics for the coming year.The Unit, 4E, data proved just the opposite as this unit encountered increases in both falls and pressure ulcer prevalence. According to the date obtained regarding falls, it is apparent that nursing care hours showed a relational trend with falls. In other words, when the nursing care hours decreased, falls increased. In comparison, when nursing care hours increased, the falls rate decreased. Drastic increases in falls occurred during June, Septem ber, November, celestial latitude and February. Nursing hours during this time averaged 15 hours per shift. It appears the overtime hours occurred as a result of the vacation season and therefore caused nursing burnout. out-of-pocket to vacations, holidays, and absenteeism, nurses are often required to engagement overtime. This pattern is obvious again during the spendmonths when accommodations for vacations are necessary.However, the opposite is true with regards to pressure ulcers vs. nursing care hours. When the nursing care hours increased, the occurrences of pressure ulcers increased as well. This is perchance caused due to increased overtime hours resulting in the fatigue and burnout. This is a perfect environment for errors or the potential to cause harm. A more extensive study in the nursing care hours must be implemented in order to establish an aggressive corrective action plan to reduce the occurrences of pressure ulcers and falls. If the study shows the nursing staf f to be working overtime, spare staff may be necessary as part of the corrective action plan. Hiring additional nurses will improve patient care, result in decreased swage rates, and lead to increased job rejoicing which will ultimately lead to corroborative outcomes in patient care.STAFFING PLANHiring and retaining an decent number of satisfactory nurses is the greatest repugn facing hospitals and other healthcare organizations. Nursing has to work with the human resources department to improve hiring procedures. Human resources should implement plans to recruit competent nurses with the skills and education necessary to provide the care Nightingale is known for. Human resources will perform an analysis to determine the best qualities for nursing candidates and will recruit agree to that standard. Additionally, alternative plans for additional staffing during known periods of absenteeism such as vacations and holidays will be constructed. It is arbitrary that nursing cove rage does not become impaired due to absenteeism.In order to attract and retain the best nurses, Nightingale needs to improve the benefit package. Nurses have often stated that caring for their patients is a joy, but administrative duties, non-nursing activities, and poor staffing practices results in low job satisfaction. Increased job satisfaction in turn, results in ameliorate patient care and increased verifying outcomes. Studies have shown that sad nurses have unhappy patients.Other strategies that Nightingale Community Hospital can implement are to come along nurses to cross train in treble units in order to fill positions in other units when staffing shortages occur. Inadequate staffing levels can cause considerable harm to the patients but is also a financial burden to the organization. inauspicious events are more common when staffing levels are low which are associated with increased costs due to the need for more intensifier nursing care. (Stanton, 2004) The Utiliz ation Guide for the ANA Principles for Nurse Staffing suggests the use of patient classification systems. (Utilization authorise for the ANA principles for nurse staffing, 2005)Utilizing a patient classification system provides guidelines for difficult staffing issues by identifying processes and procedures for improved staffing. Organizations benefit by supporting nursing judgment regarding individual patient needs, incorporating sources that honor standards of nursing practice, encouraging nursing society evaluating products that may be used in staffing decision making, and champion the use of patient classification systems.Works CitedDall, T. C. (2009). The Economic regard as of Professional Nursing. Medical Care, 97-104.Joint Commission. (2010). charge of Human Resources. CAMH Comprehensive Accreditation Manual for Hospitals, Hr-1 HR-10.Stanton, M. R. (2004, March). Hospital Nurse Staffing and Quality of Care. investigate in Action. Rockville, MD, USA Agency for Healthcare Research and Quality.(2005). Utilization guide for the ANA principles for nurse staffing. Washington, DC American Nurses Association.