ACREDITATION AUDIT 1
WGU AFT2 Task 1 |Latest Update with Complete
Solution
Accreditation Audit
Jasdeep Sandhu
Western Governors University
Table of Contents
Executive Summary for The Joint Commission Standards Compliance 3
A1. Plan for Compliance 5
A2. Justification 6
References 8
Accreditation Audit
Executive Summary for The Joint Commission Standards Compliance
Nightingale Community Hospital is a not-for-profit acute care hospital with 180 beds.
Our hospital not only provides quality health care services to the community but also serves
them with cost-effective treatments and preventative procedures. Nightingale's mission is to
provide a healing environment for the patients, and its vision is to be a hospital of choice for the
patients, the employees, physicians, and the community. Therefore, we must be prepared for the
Joint Commission survey in the next 13 months and maintain the accreditation to prove our
commitment to continuously improving healthcare services.
, ACREDITATION AUDIT 2
It is to be noted that all the Joint Commission surveys are announced, and at any time, it
is very important for us not to delay the improvement plan. The priority focus is on the four areas
of the hospital:
1. Infection Control
2. Information Management
3. Medication Management
4. Communication
To prepare and be compliant with the Joint Commission's next visit, I am presenting this
executive summary after reviewing Nightingale Hospital's compliance with the Joint
Commission's communication standards. In this review, three Universal Protocols (UP) and
thirteen Elements of Performance (EPs) of the Joint Commission's newest National Patient
Safety Goals are compared with the current surgical communication of policies and procedures
of the Nightingale hospital.
Compliance Status
After performing a thorough review of the 13 Elements of Performance (EP) and Universal
Precautions (UP), against the hospital's existing protocols, the following elements need attention
to be compliant with the Joint Commission's standards.
1. The hospital is non-compliant with the Joint Commission's UP 01.01.01. This UP
states that you should conduct a pre-procedure verification. This step is very essential
for the proper verification of the patient before the procedure. Hospitals' current site
identification and verification policy is not compliant with the Elements of
Performance standards.
EP: Identify the items that must be available for the procedure and use a
standardized list to verify their availability. (Joint Commission, 2019) In the hospital
pre-procedure checklist, there is no area that can record all the items that should be
WGU AFT2 Task 1 |Latest Update with Complete
Solution
Accreditation Audit
Jasdeep Sandhu
Western Governors University
Table of Contents
Executive Summary for The Joint Commission Standards Compliance 3
A1. Plan for Compliance 5
A2. Justification 6
References 8
Accreditation Audit
Executive Summary for The Joint Commission Standards Compliance
Nightingale Community Hospital is a not-for-profit acute care hospital with 180 beds.
Our hospital not only provides quality health care services to the community but also serves
them with cost-effective treatments and preventative procedures. Nightingale's mission is to
provide a healing environment for the patients, and its vision is to be a hospital of choice for the
patients, the employees, physicians, and the community. Therefore, we must be prepared for the
Joint Commission survey in the next 13 months and maintain the accreditation to prove our
commitment to continuously improving healthcare services.
, ACREDITATION AUDIT 2
It is to be noted that all the Joint Commission surveys are announced, and at any time, it
is very important for us not to delay the improvement plan. The priority focus is on the four areas
of the hospital:
1. Infection Control
2. Information Management
3. Medication Management
4. Communication
To prepare and be compliant with the Joint Commission's next visit, I am presenting this
executive summary after reviewing Nightingale Hospital's compliance with the Joint
Commission's communication standards. In this review, three Universal Protocols (UP) and
thirteen Elements of Performance (EPs) of the Joint Commission's newest National Patient
Safety Goals are compared with the current surgical communication of policies and procedures
of the Nightingale hospital.
Compliance Status
After performing a thorough review of the 13 Elements of Performance (EP) and Universal
Precautions (UP), against the hospital's existing protocols, the following elements need attention
to be compliant with the Joint Commission's standards.
1. The hospital is non-compliant with the Joint Commission's UP 01.01.01. This UP
states that you should conduct a pre-procedure verification. This step is very essential
for the proper verification of the patient before the procedure. Hospitals' current site
identification and verification policy is not compliant with the Elements of
Performance standards.
EP: Identify the items that must be available for the procedure and use a
standardized list to verify their availability. (Joint Commission, 2019) In the hospital
pre-procedure checklist, there is no area that can record all the items that should be
