1
Nightingale Community Hospital Readiness Review
Western Governors University
AFT2_Task1
, 2
Nightingale Community Hospital Readiness Review
The Joint Commission provides a framework of quality and patient safety to accredited
organizations ensuring that these organizations remain continually ready in an environment of
regulatory changes to ultimately achieve patient safety. This executive summary is a
comprehensive review of the 12 Elements of Performance (EP) included in the Universal
Protocol of The Joint Commission (JC). Given the central role that compliance with these EP’s
plays in our organization’s operation, safety, and reputation, it is crucial that we delineate and
understand our current status concerning these guidelines in preparation for our upcoming visit.
After thorough analysis, it has become evident that there are certain aspects of our Site
Identification and Verification (Universal Protocol) Policy that are not currently in full
compliance, necessitating immediate attention and action. Considering these findings, we will
outline specific recommendations to address these areas of non-compliance to enhance our
commitment to maintaining high-quality and safe care standards. Moreover, these
recommendations will serve as a road map for instituting necessary changes and augmenting our
performance to be in adherence with The Joint Commission’s standards. Focus on rectifying
identified gaps and ensuring continuous quality improvement in our services is of utmost
importance.
Compliance Status
When evaluating Nightengale Community Hospital’s Universal Protocol Policy it is
imperative that we consider how the existing policy aligns against the 12 Elements of
Performance included in The Joint Commission. The following areas are requirements of The
Joint Commission.
UP.01.01.01 – Process to verify details before proceeding with the procedure (2 EP’s)
Nightingale Community Hospital Readiness Review
Western Governors University
AFT2_Task1
, 2
Nightingale Community Hospital Readiness Review
The Joint Commission provides a framework of quality and patient safety to accredited
organizations ensuring that these organizations remain continually ready in an environment of
regulatory changes to ultimately achieve patient safety. This executive summary is a
comprehensive review of the 12 Elements of Performance (EP) included in the Universal
Protocol of The Joint Commission (JC). Given the central role that compliance with these EP’s
plays in our organization’s operation, safety, and reputation, it is crucial that we delineate and
understand our current status concerning these guidelines in preparation for our upcoming visit.
After thorough analysis, it has become evident that there are certain aspects of our Site
Identification and Verification (Universal Protocol) Policy that are not currently in full
compliance, necessitating immediate attention and action. Considering these findings, we will
outline specific recommendations to address these areas of non-compliance to enhance our
commitment to maintaining high-quality and safe care standards. Moreover, these
recommendations will serve as a road map for instituting necessary changes and augmenting our
performance to be in adherence with The Joint Commission’s standards. Focus on rectifying
identified gaps and ensuring continuous quality improvement in our services is of utmost
importance.
Compliance Status
When evaluating Nightengale Community Hospital’s Universal Protocol Policy it is
imperative that we consider how the existing policy aligns against the 12 Elements of
Performance included in The Joint Commission. The following areas are requirements of The
Joint Commission.
UP.01.01.01 – Process to verify details before proceeding with the procedure (2 EP’s)
