Accreditation process for identifying and resolving safety quality issues

Perodic Performance Review

Periodic Performance Review

Discuss the current compliance status of the healthcare facility

The Hospital works towards ensuring safety of the patients through the development of values and principles guiding professional operations. The priority of the health facility rests on the patients thus accomplishing safety and service compliance. The organization also scores highly in relation to partnerships and alliances. These community partnerships enable the facility to extend its services to a wider coverage of the modern society. This value improves the health condition of the nation hence development towards higher living standards. Nightingale Community Hospital accomplishes the needs to foster effective and efficient workforce in relation to the goals and objectives of the facility (Hayes, 2012).

Professional doctors and nurses operate towards the set goals and objectives to provide effective and efficient services to the entire community. The other current compliant in relation to the health facility is in the principle of accountability. The health facility promotes ethics of accountability and transparency in interactions with their patients and financial aspect of the entity. This value enables the health facility to promote quality health relations within the community. The health facility scores highly in improving modes of communication. These are in both documentation and verbal modes of communication hence crucial to the development of the health facility. Nightingale Hospital scores almost one hundred percent in relation to improvement on unacceptable abbreviations within its operations (Hayes, 2012). Improvements on the unacceptable abbreviations ensure effective communication within interactions and connections with patients. The health facility enhances its efforts to ensure safety of the patients.

This applies through labeling of containers and effective instructions within the facility. The organization also works towards the elimination of effects on the patients because of medication. This is by the appropriate application of drugs and directives from the health professionals from the organization. This occurs in the process of evaluation of therapy cases. Nightingale Hospital works towards the realization of the goal of complying with the hand washing standards. This reflects on the upward growth of the hand washing practices within the community. The hospital fairs averagely in reducing the number of patients suffering because of falls (Hayes, 2012). The harm of falls is still evident in the operations of the organization hence represents an area where improvement is needed to accomplish the standards of the facility. In the universal protocol, the health facility is excellent in being compliant to the standards. This is extremely efficient in meeting the needs and requirements of the patients as they seek medical attention.

Discuss any trends evident in the case study that may cause the organization not be compliant with the Joint Commission standards for patient care

One of the evident trends of health operations within the organization is on the use of unacceptable abbreviations by medical professionals. This is lack of compliant with the standards governing the provision of health programs. Nurses use unacceptable abbreviations in their notes and execution of physician orders in relation to serving the patients. There is the existence of smoke penetration walls that endangers the living conditions of the patients seeking medical assistance. The health program within the facility lacks pain assessment and reassessment consistently. This reflects on the documentation system within the health facility thus lack of compliant with the Joint Commission Standards (McLaughlin, 2011). There exists indirect approach to the verbal orders. There is a prohibition of verbal orders in relation to three days duration. The health facility complies indirectly to the verbal orders for forty hours.

There is the lack of compliant with consistency of the procedures concerning reassessment. Few nurses follow the order policy while executing their roles such administration of drugs and other services to patients. The priority of health facility should be on the patients thus lack compliant with the standards of the joint commission standards. Life safety within the building is still under threat due to the presence of mobile phones, computers, medical carts, stools, and linen carts close to fire extinguishers. This puts the lives of the patients seeking medical assistance at risk thus lack of compliant with the joint commission standards. Accumulation of these trends in the interaction of the health organization with the patients results into lack of compliant to the joint commission standards (McLaughlin, 2011).

Review the performance improvement standard regarding staffing in the healthcare facility's patient care unit by doing the following:

Analyze the data to determine the staffing patterns of the patient care unit

In order to ensure effectiveness and efficiency in service delivery, Nightingale Hospital adopts the use of data and information from clinical indicators and human resources in relation to screening processes. Medical professionals within the health facility operate towards the realization of the goals and objectives of the organization. This makes it critical to execute their roles in relation to the needs and demands (priorities) of the health facility. In order to determine the effectiveness of role execution in relation to patient caring unit, the organization applies the use of nursing balanced scorecards. Balanced scorecards enable the organization to evaluate both clinical and human resource indicators within the health facility. Staffing patterns of patient care develops in two unique methods within the organization. Nightingale Hospital has both 3 East and 4 East wings to tackle the increasing number of patients visiting the organization. Nursing 3 East wing of the organization enhances their performances through attendance of health seminars. This enables them to reduce the presence of falls within their areas of jurisdiction. Example of such seminars includes the Nurses Improving Care for Healthcare Elders. The seminar enables the nurses to learn on the how to relate to the elders while taking care of their needs. Effective and efficient application of the program limits the number of falls, overtime, and disease indicators in the overall evaluation of the process. There is constant supervision of appropriateness of staffing within the health facility. This approach aims at identification of the shortcomings and falls of the organization in order to adopt appropriate measures to revive the facility from the situation (Hayes, 2012).