Evaluation Essay on Nightingale Community Hospital

The Existing Compliance Status for Nightingale Community Hospital

The healthcare facilities are required to comply with the set Joint Commission Standards and meet the Accreditation Participation Requirements for better and quality services. This analysis report will provide an assessment of the Nightingale Community Hospital and its compliance to the standards. The available audit reports reveals that the organization maintained a significant compliance to The Joint Commission (JC). For instance, the investigation reveals that the emergency management at Nightingale Community Hospital is in compliance with the JC standards. This is an indication that the hospital is in a good position to respond to the various possible emergencies or calamities. Emergency response action plan for every healthcare system is essential as it guarantees the patients urgent and proper attention in case of tragedies.

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Another current compliance with the Nightingale Community Hospital is seen in its staffing standards. Human resources are well-managed to ensure compliance with the set standards. For instance, the organization observes the regulations in its recruitment process. Staffs with sufficient qualifications are employed, oriented and continually evaluated for their performance to ensure they fit in their specific positions. The hospital has also adopted proper measures to comply with the infection control measures by properly monitoring, analysing and utilizing proper strategies and the action plan to minimize infections within the healthcare facility. Nightingale Community Hospital has adopted effective policies and procedures to facilitate transplant safety standards. This is through compliance with the predetermined roles and responsibilities of every individual and recognition of the fundamental rights of the patient and observing them properly.

However, with the above-discussed strengths and compliance with the Joint Commission standards, Nightingale Community Hospital was found to have several cases of non-compliance. The focused standard assessment (FSA) report which involved various elements such as Environment of Care (EC), Record of Care services RC, Life Safety, Information Management, The Nursing, Provision of Care services, Medical Staff (MS) and many others. It was noted that the hospital violated the standards regarding the environment of care for its penetration to the firewalls. The Nightingale Community Hospital made use of unapproved abbreviations which is against the information standards. The audit report explains that some nurses complained of been overwhelmed with work due to the understaffing in the hospital. Most nurses are much busy with documentation which takes much of their time that could have been used to serve the patients (Mujumdar & Santos, 2014). It was not as per the NR provision. The FSA also reveals that Nightingale Community Hospital was not able to meet the standards for the Provision of Care services in some of its occasions. For instance, the verbal orders could not be authenticated on time and thus, compromising with the record of care standards. The hospital is currently racking appropriate standards level of communication which is one of the primary focus of the JC. There is much need to address the identified noncompliance issue to prevent future problems or unexpected advance consequences.

The Trend Evident for Non-compliance

The past trend of the various non-compliance may be associated with future problems. For instance, the environment care had several notable errors for the non-compliance as indicated in the focused standard assessment. The analysis revealed clutter and other several penetrations in the firewall. However, the necessary fire drills were never conducted of the provided by the role of regulation. It is indicated that this should happen on a quarterly basis, but Nightingale Community Hospital ignores this. There should be periodic inspection conducted to ensure the firewalls are always in their ordinary condition and well-functioning. When fire drills are not held in compliance with the set regulations, it may lead to a notable trend that is more likely to affect the patient care. As the Joint Commission will be conducting an audit review, it is essential to consider an analysis of the available data to know the key areas to pay more attention. The previous audit report is critical in developing the action plan in the investigation process of assessing the compliance or non-compliance with the set standards.

The Focused Standard Assessment has recorded various areas of non-compliance as discussed above. From the previous audits, there was a notable trend in the communication process of the Nightingale Community Hospital. The compliance rates of the various performance measures were ranging from 60-90% over a period of one year, from January to December. The rate was much lower than expected for a more extended period and thus, much needs to be done to improve the quality of the patient care and avoid any future risk that might be associated. Healthcare facilities audit should also consider incorporation of the organizational trends to enable them for effectively executing their roles. Joint Commission should also provide suggestions and recommendations for the firm's strategies for enhancing the quality of the patient care.

The Staffing Patterns of the Patient Care Unit

Staffing effectiveness which refers to the quantity, competencies, and skills of the healthcare staffs needed to treat. Human resource screening is used as an indicator of measuring the continuous improvement of the healthcare services. For the analysis of the accreditation audit of Nightingale Community Hospital involved various units and the impact of nosocomial pressure ulcers on 3East-Oncology, 4East unit, and Intensive care unit. These units were assessed in relation to the fall in the nursing hours. It was noted that the hospital implements various strategies for improvement to address the rising falls as well as the pressure ulcers. The nurses were exposed to training to advance their skills for better patient care and more specifically to the old adults where the conditions seem to be higher. There was a consistent staffing hour since there were no changes in the trends.

In addition, 4-East unit indicated a significantly different situation. There was a notable rise in falls and pressure ulcers. However, the worked nursing staff hours were also not consistent as the nurses take more than the case with the 3-East Oncology. The inferences made here is that the loner the working hours the higher the falls and the pressure ulcers. The other unit investigated is the intensive care unit, and there was a notable increase in the fall rate. Therefore, it implies that there was successful execution of the plans that were meant to reduce the fall rate. The staffs in the ICU unit were involved, and the data from the investigation shared with the other healthcare providers. This would help in identifying the appropriate staffing requirements within the organization to meet the patient's needs better.

Suggested Staffing Plan

The various stakeholders should play their part to ensure that the healthcare facilities have got sufficient nursing staffs. This is in the attempt of guaranteeing proper services and adequate protection of the patients. Healthcare stakeholders include the hospital's administrators, insurance companies, regulating agencies, and the accrediting agencies. They should all work together to ensure the improvement of the quality of the healthcare services offered to the patient (Needleman et al., 2002). Appropriate strategies should also be developed to establish the most appropriate nursing numbers to meet the healthcare demand. A high number of nurses is recommended for better healthcare. For instance, to address the issue of the rising falls and pressure ulcers, Nightingale Community Hospital will be required to increase the nursing hours.

A staffing plan to promote the employee's involvement for better results will be part of the staffing plan. Creating a participative working environment is essential in improving the general performance of the healthcare service providers (Mujumdar & Santos, 2014). The individual hired by the organization will have to meet the set requirements for identification of competitive workers. The recruited nurses will join the fall prevention team, and they will be equipped with the required necessary skills for sufficient implementation of the set goal. Periodic training and mentorship will be offered to ensure continuous skills' development. The managers and departmental leader will be in charge of monitoring the healthcare service providers and providing the report on the staff attendance rate. The reporting system is expected to be on a quarterly basis, and the report should go to the stakeholders concerned such a Quality Assurance Committee. These strategies will help in improving the quality of the services to the clients. The working for 12 hours may also affect the performance of the nurses and hence a maximum of 8 to 10 hours per shift is recommended (Clendon, & Gibbons, 2015). The proposed staffing plan for Nightingale is therefore in acquiring more nurses as well as offering training to develop the existing workforce for the attainment of the set goals and objectives.

References

Clendon, J., & Gibbons, V. (2015). 12 h shifts and rates of error among nurses: A systematic review. International Journal of Nursing Studies, 52(7), 1231-1242 12p. doi:10.1016/j.ijnurstu.2015.03.011

Mujumdar, S., & Santos, D. (2014). Teamwork and communication: an effective approach to patient safety. World Hospitals and Health Services: The Official Journal of the International Hospital Federation, 50(1), 19-22.

Needleman, J. Ph.D., Buerhaus, P. Ph.D., R.N., Mattke, S. M.D., M.P.H., Stewart, M. B.A., and Zelevinsky, K. (2002). Nurse-Staffing Levels and the Quality of Care in Hospitals. The New England Journal of Medicine, 346:1715-1722.