Aft2 Task 4 Essay

1716 Words Feb 26th, 2013 7 Pages
A1. Status

Preparing for The Joint Commission, Nightingale Community Hospital reviews areas of compliance and non-compliance. A periodic performance review, which is a self-evaluation, is utilized by Nightingale Community Hospital, to prepare for The Joint Commission. The Joint Commission has eighteen accreditation requirements. (Commission, 2013) The periodic performance review found the hospital to be compliant and non- compliant in the following areas:

Compliant: Emergency Management Human resources Infection Prevention and Control Performance Improvement Right and Responsibilities of the Individuals Transplant Safety Waived Testing
Non- Compliant Environment of Care Leadership Life Safety Medication
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In addition, the antiseptic dispensers will be visible and accessible to the nursing staff helping in the reduction of nosocomial pressure ulcers. The improvements in efficiency and effectiveness will also help reduce the nursing overtime.
Utilizing the Plan Do Study Act Model the director of 4 East needs to survey and discuss with staff the current staffing issues. In addition, the working environment needs to be evaluated for efficiency and effectiveness. A hospital functions properly when you look at every aspect as a whole. Every area of non-compliance affects every area of the hospital.

A3b. Staffing Plan

As a team, administration and the director of 4 East will review the purposed staffing plan and form an action plan to address non-compliant areas. Addressing the needs of each unit, specifically 4 East, requires staff to understand the dynamic patient acuity. The patient’s needs may change from shift to shift, e.g., need for a blood transfusion, or the need for aggressive respiratory toleting. As the needs of the patient change so does the acuity for nurse to patient ratio; however, the hospital has to remain in compliance with California state laws. California laws require a minimum nurse to patient ratio of pediatric patient to be 1:4 ("70217. Nursing service staff." 2003).
Following a classification system, manually or by a computer, can determine the acuity of each patient, which categorizes the patient as low or high (Jones 2009). By

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