1
Nightingale Compliance Audit
Belizath Doe
School of Business, Western Governors University
Ashley Tennessee
03/02/2026
, 2
Executive Summary
Nightingale Community Hospital is a 180-bed acute care facility providing
comprehensive medical services across 12 specialty areas. These 12 speciality areas are level
two nursery, obstetrics, general medical and surgical services, cardiology, orthopedics,
telemetry care, oncology, endoscopy and surgery, vascular laboratory services, imaging
services, and a neuroscience unit. The organization’s core values—safety, community,
teamwork, and accountability—reflect its commitment to delivering high-quality patient care and
taking corrective action when performance does not meet established standards. (WGU, 2026)
Compliance Audit on Communication
A prior survey identified several key areas that Nightingale Community Hospital must
address in preparation for its upcoming review by The Joint Commission. The four primary focus
areas include information management, medication management, infection control, and
communication. Using The Joint Commission’s Elements of Performance (EPs) as a framework,
three communication standards will be assessed to determine whether Nightingale Community
Hospital complies with them.
UP.01.01.01: Conduct a Pre-Procedure Verification Process (Aorn, 2025)
● EP 1: Before any procedure, confirm the correct procedure, the correct patient, and the
correct site. Include the patient in this check whenever possible. (Aorn, 2025)
○ Nightingale Community Hospital complies with this standard by implementing a
Universal Protocol policy for site identification and verification. This policy
outlines preoperative and preprocedure verification steps, procedures for marking
the operative or invasive site, time-out procedures, and bedside procedures, and
encourages patient involvement in the verification process.
● EP 2: Identify the items needed for the procedure and use a checklist to make sure they
are available. This includes the correct documents, labeled test and radiology results,
blood products, implants, devices, and any special equipment. (Aorn, 2025)
Nightingale Compliance Audit
Belizath Doe
School of Business, Western Governors University
Ashley Tennessee
03/02/2026
, 2
Executive Summary
Nightingale Community Hospital is a 180-bed acute care facility providing
comprehensive medical services across 12 specialty areas. These 12 speciality areas are level
two nursery, obstetrics, general medical and surgical services, cardiology, orthopedics,
telemetry care, oncology, endoscopy and surgery, vascular laboratory services, imaging
services, and a neuroscience unit. The organization’s core values—safety, community,
teamwork, and accountability—reflect its commitment to delivering high-quality patient care and
taking corrective action when performance does not meet established standards. (WGU, 2026)
Compliance Audit on Communication
A prior survey identified several key areas that Nightingale Community Hospital must
address in preparation for its upcoming review by The Joint Commission. The four primary focus
areas include information management, medication management, infection control, and
communication. Using The Joint Commission’s Elements of Performance (EPs) as a framework,
three communication standards will be assessed to determine whether Nightingale Community
Hospital complies with them.
UP.01.01.01: Conduct a Pre-Procedure Verification Process (Aorn, 2025)
● EP 1: Before any procedure, confirm the correct procedure, the correct patient, and the
correct site. Include the patient in this check whenever possible. (Aorn, 2025)
○ Nightingale Community Hospital complies with this standard by implementing a
Universal Protocol policy for site identification and verification. This policy
outlines preoperative and preprocedure verification steps, procedures for marking
the operative or invasive site, time-out procedures, and bedside procedures, and
encourages patient involvement in the verification process.
● EP 2: Identify the items needed for the procedure and use a checklist to make sure they
are available. This includes the correct documents, labeled test and radiology results,
blood products, implants, devices, and any special equipment. (Aorn, 2025)
