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Accreditation compliance is an essential topic in contemporary healthcare management since it is crucial for organizations to continue operating and providing high-quality medical services to populations. To facilitate compliance, managers should evaluate the status of their institutions regularly and make corrections to make the accreditation process easier and avoid issues. The Joint Commission is an excellent resource for organizations wishing to improve and maintain compliance since they publish relevant documentation that can be used for self-assessments and compliance checks. The present paper will seek to evaluate the current compliance status of the Nightingale Community Hospital, examine negative trends, and develop a plan for improving staffing levels that would help the organization to meet the required standards.
Current Compliance Status
The eighteen standards of the Joint Commission that apply to the case are
- Accreditation Participation Requirements – Compliant, as the medical institution, timely submitted the required data, provided accurate information throughout the accreditation process, and allowed the Joint Commission to use the reports from publicly recognized organizations.
- Emergency Management – Compliant due to the available Emergency Operations Plan containing the communicative strategy and managing the resources and assets, as well as the safety and security policies in the case of an emergency.
- Environment of Care – Non-compliant due to the insufficient adherence to the safety standards, which was proven by the smoke wall penetrations on the 1st and the 4th floors and inappropriate life safety measures testing.
- Human Resources – Compliant. The audit has shown that the hospital defined and verified staff qualifications, hence, determining the way and the manner the medical personnel functioned within the organization.
- Infection Control – Compliant, as the institution has proven its responsibility in identifying the risks of transmitting infections, as well as providing the experienced employees and the needed resources to maintain the standards of the infection prevention and control program.
- Information Management- Non-compliant, as the audit has shown that the progress and nursing notes, as well as physician orders, contained inappropriate and not standardized abbreviations, which could, subsequently, lead to misinterpreting the information provided.
- Leadership- Non-compliant; the lack of administering control resulted in the inappropriateness of documenting the necessary information, thus, leading to excessive workload. Non-compliance with the leadership standard showed the importance of restaffing in the medical institution.
- Life Safety- Non-compliant. Observations during the PPR rounds have revealed the issues concerning life security. These include clutters in hallways and inadequate fire drill processes, with their frequency not meeting the standards of life safety for an organization providing people with medical services.
- Medical Staff- Non-compliant, as the summary of the ongoing data collected to evaluate the medical staff’s competence does not meet the standards of the OPPE policy.
- Medication Management- Non-compliant proven by the inadequate processes of following the range order and range dose policies, as well as by the presence of unlabeled medical equipment.
- Nursing – Non-compliant. Lack of nursing staff and, subsequently, the excessive workload, as well as the insufficient nurse-to-patient ratio, lead to ineffective providing the patients with medical services.
- Performance Improvement – Compliant because the data intended to control the organization’s performance is collected and thoroughly analyzed.
- Provision of Care – Non-compliant, the absence of the day of Procedure Reassessment has been found in numerous cases throughout the auditing process.
- Record of Care – Non-compliant, as the chart reviews during the PPR rounds and the PI audit, displayed that verbal orders were not authenticated within 48 hours.
- Rights and Responsibilities – Compliant, proven by the fact that patients’ rights are respected, protected, and promoted.
- National Patient Safety Goals – Non-compliant, as the observed unlabeled basins together with the prelabeled syringes in cataract packs from external suppliers do not correspond to the NPSG policy.
- Transplant Safety – Compliant due to the fact that the hospital strictly adheres to the policies and procedures for safe organ and tissue donation, procurement, and transplantation.
- Waived Testing – Compliant. The established and approved policies for waived tests allow the medical organization to meet the waived testing standards.
The aspects of the facility that comply with the Joint Commission standards are emergency management, human resources, performance improvement, rights and responsibilities, transplant safety, and waived testing. The rest of the areas show some evidence of non-compliance, which should be addressed as part of the quality improvement initiative.
The first trend evident is the uneven application of care standards, which affects the organization’s adherence to standards of records of care, provision of care, medication management, and environment of care. For example, the internal assessment has identified breaches in the use of unacceptable abbreviations and the authentication of verbal orders. Additionally, nurses did not follow range order policy and failed to record the day of procedure reassessment in case documentation as required. Failure to enhance compliance in these areas can lead to difficulties with accreditation. Furthermore, these problems could contribute to the incidence of medical errors, wrong patient or wrong site treatments, and other related issues that threaten patient safety and decrease the overall quality of care provided in the hospital. Thus, the organization should address these trends promptly to avoid negative consequences.
Another trend that was found during the investigation is problems with nursing practice and management. For example, the OPPE process did not meet relevant standards, and nurses failed to maintain consistent documentation due to being “too busy.” The latter fact suggests that the workload of nurses is too high, preventing them from following process requirements and standards correctly. This can also be connected to the issues relating to information management, treatment, and environment of care. For example, clutter in hallways could be due to nurses being overworked and busy with patients. Similarly, the lack of adherence to documentation standards and record-making procedures could also be linked to a high workload. The fact that nurses claim to forget some of the requirements due to their workload also indicates that there might be issues with staffing levels. If the organization does not have enough nurses per patient, this could cause further problems, such as decreased patient safety and satisfaction. This possibility necessitates a further inquiry into nurse staffing levels.
The third trend discovered as part of the assessment was that some aspects of the environment did not meet safety standards, thus threatening compliance with emergency management, life safety, and environment of care standards. For example, smoke wall penetrations were reported in various units, appropriate ILSM was not initiated during three construction projects, and the fire drill process was inaccurate. In case of an emergency, these problems can pose a threat to the safety of patients and care providers operating in the institution. Therefore, the organization should make sure that all relevant safety standards and regulations are addressed as part of its quality improvement processes. This will help to avoid issues related to accreditation while also protecting the health and safety of workers and patients who are being treated in the facility.
Overall, there are some organizational processes and practice areas that lack compliance with critical standards established by the Joint Commission. Some of the problems identified as part of the review could be connected to one another, such as the issues relating to misdocumentation and nurses’ workload. Other problems, however, require the specific attention of responsible persons as they relate to maintenance and emergency management. Fixing the issues identified in the review is essential to ensure the organization’s compliance with all eighteen accreditation standards.
For the organization to improve on some of the aspects identified in the previous section, it is essential to evaluate current staffing patterns. The report on staffing effectiveness defines two key groups of indicators used in the hospital to assess staffing: clinical indicators and human resource indicators. The clinical indicators vary depending on the unit, but human resource indicators are the same throughout the hospital and include nursing care hours and overtime. The use of these indicators is justified by the impact that nurse staffing levels have on patient safety and clinical outcomes (Kim, Kim, Park, & Lee, 2019; Needleman et al., 2002; Spetz, Donaldson, Aydin, & Brown, 2008). Therefore, the practices related to the organization’s assessment of staffing patterns are correct.
The data provided by the hospital reveal various relationships between nurse hours and clinical indicators. In Oncology, the linear graph shows a slow increase in the number of falls that matches a decrease in nursing care hours over the same time. Similarly, the rate of pressure ulcers is negatively correlated with nursing care hours per day, as indicated by the graphs. In 4-East, the overall trends are the opposite, with falls and pressure ulcer rates increasing along with nursing care hours. This could be due to various factors, such as nurses’ burnout, lower qualifications, or decreased experience, as well as because of patient population characteristics, including age and severity of illness. Finally, the Intensive Care Unit showed no correlation between nursing care hours and falls or ventilator-associated pneumonia. Based on the results of the assessment, it is important to address staffing levels in Oncology, as this would help to improve patient outcomes and reduce the incidence of falls and pressure ulcers.
Addressing the issue of falls in the hospital is critical because they threaten patient health and treatment outcomes. The injuries that patients suffer as a result of falls can prolong their hospital stay, increase medical expenses, and lead to legal consequences for the institution (King, Pecanac, Krupp, Liebzeit, & Mahoney, 2018; Slade, Carey, Hill, & Morris, 2017). Hence, it is essential to support a meaningful improvement in staffing levels that would result in falls prevention.
The main nursing specialization that would be of interest in the present case is Certified Nursing Assistants. CNAs work more closely with patients than other nursing specialties while also being able to perform a wide array of duties that could relieve the workload of Registered Nurses and other care personnel. By seeking patients several times daily and helping them with various tasks, CNAs can contribute to the prevention of falls by assisting with movement or removing clutter in patient wards. Thus, it is likely that hiring more CNAs will help to reduce fall rates in the hospital.
Table 1. Proposed staffing chart.
|# of RN||# of LPN||# of CNA|
The proposed staffing chart to help in solving the falls issue can be found in Table 1. Based on this chart, the number of registered nurses would be sufficient to provide patients with key medical services. At the same time, LPNs will be able to support the unit’s operations by performing supplementary tasks, and CNAs will always be available to assist patients to minimize fall risk. The support of CNAs is particularly important at night since patients might need assistance moving around in the dark, which is why more CNAs are required during this time than other nurses. It is anticipated that the proposed staffing plan will help the hospital to improve patient outcomes and reduce patient safety risks.
Overall, the review of the case has helped to identify some gaps with respect to standard compliance. Specifically, the negative trends included policy non-compliance, staff issues, and environmental safety problems. These can have a negative effect on the organization, its patients, and accreditation. Staffing patterns were also analyzed, revealing a correlation between nurse hours and patient falls in one of the units. The proposed staffing plan takes this issue into account, suggesting a way to improve the situation through staffing. Consequently, implementing this plan will help the hospital to address patient safety concerns and improve compliance with accreditation standards.
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Kim, J., Kim, S., Park, J., & Lee, E. (2019). Multilevel factors influencing falls of patients in hospital: The impact of nurse staffing. Journal of Nursing Management, 27(5), 1011-1019.
King, B., Pecanac, K., Krupp, A., Liebzeit, D., & Mahoney, J. (2018). Impact of fall prevention on nurses and care of fall risk patients. The Gerontologist, 58(2), 331-340.
Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-staffing levels and the quality of care in hospitals. New England Journal of Medicine, 346(22), 1715-1722.
Slade, S. C., Carey, D. L., Hill, A. M., & Morris, M. E. (2017). Effects of falls prevention interventions on falls outcomes for hospitalised adults: Protocol for a systematic review with meta-analysis. BMJ Open, 7(11), e017864.
Spetz, J., Donaldson, N., Aydin, C., & Brown, D. S. (2008). How many nurses per patient? Measurements of nurse staffing in health services research. Health Services Research, 43(5p1), 1674-1692.