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Western Governors University - AFT2 - Task 4
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- Western Governers University
Western Governors University - AFT2 - Task 4
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Running Head: AFT2 – Task 4 1AFT2 – Task 4
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Western Governors University AFT2 – Task 4 1
Executive Summary
Meeting The Joint Commission’s compliance standards is of the upmost priority to Nightingale Community Hospital to achieve goals in improved patient safety and healthcare practices. As such, an internal inquiry was conducted as part of the hospital’s continuous accreditation compliance process. The evaluation found eight areas of compliance out of a total of eighteen, indicating a pressing need for quality improvement moving forward. The following review will summarize the importance of meeting the areas found in compliance, in addition to trends in non-compliance areas.
The internal review also analyzed staffing patterns of three different units: 3 East – Oncology, 4 East, and the Intensive Care Unit (ICU). Problem areas such as the use of overtime and its effects on patient outcomes will be addressed with new staffing plans. Additional staff training and education plans will also be considered to achieve improved patient outcomes. A1: Compliance Status
Areas Compliant:
-Accreditation Participation Requirements (APR)
oAn organization must be compliant in Accreditation Participation Requirements throughout the entirety of the accreditation cycle. Meeting this focus area will permit The Joint Commission to complete accurate surveys of the organization through each focus area. The organization is also responsible to maintain transparency during the process and ensure any submitted information is accurate and timely. -Emergency management (EM)
oMeeting Emergency Management requirements proves an organization’s ability to
identify and mitigate potential threats to patient safety, while also revealing their level of preparedness in initiating an appropriate response for recovery. The probability of emergency events happening is often uncertain, but there are critical areas that must be managed properly to usher in an effective response. This includes emergency planning for communications, resources and assets, safety and security, staff responsibilities, utilities, and patient clinical and support activities. -Human Resources (HR)
oHuman resource management is critical to an organization overall effort in patient
safety and quality care. Compliance in this area translates to a workforce that is knowledgeable, skilled, and focused on achieving the best healthcare outcomes for patients. Additionally, meeting these standards includes adequate training on hospital practices, continuing education, and regular performance reviews. -Infection Prevention and Control (IC)
oPlanning for infection prevention and control can make or break a hospital. Much of this has been especially true given the ongoing COVID-19 pandemic. A
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