Accreditation Audit AFT2 Task 4

The chart above identifies which Joint Commission standards Nightingale Hospital is complaint and not in compliance with. Some standards Nightingale is not in compliance with may affect one department or multiple. Each department will need to review standards they aren’t in compliance with and create a plan of action to fix them. After this plan of action is implemented Nightingale will be in compliance with Joint Commission standards. Noncompliant Trends Nightingale Hospital has several deficiencies that need to be addressed for the hospital to be complaint with Joint Commission standards. One trend that was found affecting multiple departments was the standard of environment of care. One element of performance under this standard is the hospital’s record of fire drills. Element of performance 1 EC.02.03.03 states “hospital conducts fire drills once per shift per quarter”, after reviewing the document “Fire Drill History” it is seen that the hospital is not in compliance. The hospital does not conduct fire drills for at least one shift. This is evident if we look at the first quarter covering January to March. During this time only the 1st and 2nd shift did their drills while the 3rd shift for this quarter. Nightingale will need to have all shifts participating in fire drills each quarter for them to be compliant with Joint Commission standards. The shifts that do not participate in fire drills will not be prepared if a real fire drill were to occur.