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Accreditation Audit Essay

1586 words - 7 pages

Executive Summary - Infection Control and Prevention Current Compliance Status for Joint Commission Accreditation
Nightingale Community Hospital is committed to providing healthcare excellence, a healing environment and to be the choice for patient care. In order to continue to provide quality healthcare services in accordance with our values of safety, community, teamwork, and accountability Joint Commission Accreditation provides guidelines and standards for the Priority Focus Areas (PFA) for the welfare and quality of patient care.
Infection control and prevention extends beyond treating the patient. It encompasses all who work and visit the facility including medical staff, ...view middle of the document...

Establishing and reinforcing Nightingale Community Hospital’s commitment to implement programs and improve on identifying, preventing and controlling infections will reduce cost of care while improving patient safety and education.
Multidrug Resistant Organisms
Current Compliance Status
Patients continue to be at risk for nosocomial transmissions that are multidrug- resistant. Nosocomial transmissions did not meet the Joint Commission Accreditation standards 7 out of the 12 months.
|Number of MDRO Infections|Rate/1000 Patient Days|
January|0|0|
February|4|1.5|
March|2|0.75|
April|2|0.5|
May|1|0.25|
June|1|0.25|
July|0|0|
August|1|0.25|
September|1|0.25|
October|0|0|
November|0|0|
December|0|0|

Although there was a reduction rate of Mulitdrug-resistant organisms (MDROs) from February through August, the 12-month rolling rate average is 3.2 infections/1000 patient days. The current goal set by Nightingale Community Hospital is < 0.15 infections/1000 patient days.
Joint Commission Accreditation Standard
Reduce the risk of health care-associated infections (2013 The Joint Commission). There are nine Elements of Performance (EPs) that are required and that have direct impact on patient care:
1. Conduct periodic risk assessments (in time frames defined by the hospital) for multidrug-resistant organism acquisition and transmission.
2. Based on the results of the risk assessment, educate staff and licensed independent practitioner about HAIs, MDROs, and prevention strategies at hire and annually thereafter.
3. Educate patients, and their families as needed, who are infected or colonized with a MDRO about healthcare–associated infection prevention strategies.
4. Implement a surveillance program for MDRO based on the risk assessment.
5. Measure and monitor multidrug-resistant organism prevention processes and outcomes.
6. Provide MDRO process and outcome data to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians.
7. Implement policies and practices aimed at reducing the risk of transmitting multidrug-resistant organisms. These policies and practices meet regulatory requirements and are aligned with evidence-based standards
8. Implement a laboratory-based alert system that identifies new patients with MDROs.
9. Implement an alert system that identifies readmitted or transferred patients who are known to be positive for multidrug-resistant organisms.
Corrective Action Plan
· Perform quarterly risk assessments of MDROs transmission and acquisition.
· Provide annual educational seminars to staff and practitioners regarding the transmission, reduction, control, and prevention of HIAs based on the quarterly risk assessment outcomes.
· Focus on family and patient education to bring awareness of reduction, prevention, and treatment of MDROs.
· Healthcare-associated infections (HAI) surveillance should identify the population who are of greater risk for...

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