Accreditation Audit Essay

1613 Words Jan 12th, 2013 7 Pages
Accreditation Audit RAFT Task 1

Executive Summary

Nightingale Community Hospital (NCH) is a hospital that states they are leaders in quality healthcare. To remain a leader in hospital care it is crucial for the hospital to adhere to standards developed by the Joint Commission Accreditation on Healthcare Organizations (JCAHO). JCAHO is the organization that accredits and certifies hospitals that meet certain performance standards nationally. Only those hospitals that have the JCAHO accreditation are ensured to be in compliance with specific guidelines in each Priority Focus Areas: Infection control, Communication, Medication Management, and
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In this section, NCH needs to add that the breast being treated needs to be marked for the procedure and delete the previous statement.
2. NCH is in compliance with the second Element of Performance including in their policy that procedure site must be marked with involvement of the patient.
3. The third Element of Performance is 100% non-compliant in that NCH states that the patient is to mark their procedure site. This section of their policy needs to be omitted and revised with the correct wording from JACHO standard that the procedure is to be marked by a licensed independent practitioner who is accountable and will be present for the procedure or an individual delegated by the practitioner that is qualified according to JACHO standards.
4. The fourth Element of Performance is met by NCH following the JACHO standard of markings being unambiguous. Their policy states how sites must be marked and with permanent marking.
5. For NCH to become compliant in the fifth Element of Performance their policy needs to be revised to include in their written justification, the alternative process not only for those patients that are not marked, but wording to include the alternative for premature infants that cannot be permanently marked.

UP.01.03.01: A time-out is performed before the procedure
1. The first Element of Performance will need editing in the NCH policy’s wording. The words missing in this clause are “invasive procedure” and “incision.”

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