Task4
Western Governors University
Compliance Status
Compliant
According to the FSA Findings for Nightingale Community Hospital in compliance in some areas, including Accreditation Participation Requirements (APR), Emergency Management (EM), Human Resources (HR), Infection Prevention and Control (...
According to the FSA Findings for Nightingale Community Hospital in compliance in
some areas, including Accreditation Participation Requirements (APR), Emergency Management
(EM), Human Resources (HR), Infection Prevention and Control (IC), Performance
Improvement (PI), Right and Responsibilities of the Individual (RI), Transplant Safety (TS), and
Waived Testing (WT).
Accreditation Participation Requirements (APR) lists out the requirements for
participating in the accreditation process and for maintaining the accreditation award. If a
, hospital is seeking to become accredited for the first time their compliance is assessed during the
initial survey, excluding APR.09.01.01 and APR.09.02.01. If the hospital is already accredited,
then compliance will be assessed via on-site surveys, the Focused Standards Assessment (FSA),
and Evidence of Standards Compliance (ESC). These methods plus periodic updates of hospital-
specific information are to be performed throughout the accreditation cycle. If a hospital is found
to not be compliant they will be assigned a Requirement for Improvement (RFI), which can
impact accreditation decisions as established by the accreditation decision rules. If an RFI is not
resolved the hospital can lose accreditation. If a hospital does not permit a survey then they will
lose accreditation. Fabrication of information results in a preliminary denial of accreditation.
Emergency Management is important because an emergency can quickly become a threat
to any health care organization. Multiple simultaneous can negatively impact patient safety and
the hospital’s ability to provide treatment or services for an extended period of time, especially if
the community cannot support the hospital. Many hazards can lead to a disruption in patient care
and even pose risks to staff and the hospital as a whole. There are four phases of emergency
management that occur over time: mitigation, preparedness, response and recovery. In most
scenario’s mitigation and preparedness occur prior to the emergency, where response and
recovery occur during and post emergencies. Hospitals should perform a Hazard Vulnerability
Analysis (HVA), which is designed to help hospitals gain an understanding of where they are
leaving themselves exposed to risk. Once they understand their vulnerabilities they are better
able to mitigate and respond. Although no one can predict how or when an emergency will
occur, hospitals can still plan for managing areas like communications, resources and assets,
safety and security, staff responsibilities, utilities, patient clinical and support activities. Taking
these areas into consideration is called an “all hazards” approach and creates the foundation for
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller helperatsof1. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $7.49. You're not tied to anything after your purchase.
