Accreditation Audit Task Essay

Custom Student Mr. Teacher ENG 1001-04 12 June 2016

Accreditation Audit Task

The Joint Commission defines the Periodic Performance Review as an assessment tool created to assist health organizations improve and monitor their performance throughout the year. This tool focuses on the processes that influence patient care and safety while providing the structure for unremitting standards fulfillment. Nightingale Community Hospital is compliant with most standards as set forth by the Joint Commission. However, upon inspection and in an effort to stay focused on compliance, our standards committee has located a few discrepancies that must be resolved to maintain our accreditation with the Joint Commission.

Rather than focus on the discrepancies found within each unit, we will look at the trends that affect the hospital’s compliance with the Joint Commissions recommendations regarding patient care. Armed with the trends, we will then explore staffing patterns and how they relate to patient care in order to establish a plan that will assist our hospital to minimize patient safety issues as they relate to falls, pressure ulcers, pneumonia, and the general safety of our patients.

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Although the Joint Commission standards clearly define the requirements for an organization to remain in compliance with the patient care and safety criterion for accreditation, Nightingale Community Hospital’s policies are not being routinely followed throughout each unit. The policy that states verbal orders must be authenticated within 48 hours is not being followed in several units and there seems to be little, if any consistency throughout the hospital with regards to policy observations. Generally, the compliance rate in the second quarter was steady and the best of all quarters, while the third quarter compliance results were very poor. Policy must be reviewed and standards improved in order to bring the hospital into compliance. Policy that should be implemented include a form in which the nurse who takes the order must sign and date the form and place it on outside of the patients chart to alert the physician that actions are required of him regarding this patient.

Only two abbreviations were monitored in ICU, Telemetry, 3E, and 4E because they are the most frequently used forbidden abbreviations. These forbidden abbreviations are “cc” and “qd”. The audit revealed “cc” was most often used in the months of April and September. The abbreviation “qd” was used much more sparingly but was used most often during the months of June and July. The second and third quarters proved to be the quarters when the two prohibited abbreviations were used the most. To increase awareness of prohibited abbreviations, a list will be posted in the nursing station in close proximity to where the charting takes place. Nurses and nursing staff will receive education regarding the use of approved abbreviations as set forth by the Joint Commission. Additionally, everyone who documents in the patients chart will be required to sign and date the entry at the time of documentation.

The pain assessment audit was another standard that was out of compliance with the Joint Commission recommendations. The ED, 3E, and PACU were the units focused on for this portion of the audit. Clearly, the Emergency Department was the least compliant throughout the year for pain assessment. This may be due to the urgency or life threatening events in which pain assessment is not a priority. Regardless of the reason for neglecting to assess for pain, it is a requirement for accreditation. Each assessment should be documented in the patient’s record of care and all personnel responsible for patient care must receive education regarding the necessity of the pain assessment. The Nurse Managers of each department has the responsibility of implementing a corrective action plan based on the particular department standard of care.

The Joint Commission’s focus is on safety. At Nightingale Community Hospital, safety is also important and the policies and procedures are reviewed to ensure the hospital is compliant with the Joint Commission’s recommendations. The hospital policy for fire drills requires one drill per shift per quarter. The audit shows that there are some compliancy concerns regarding the fire drills. During third shift, for the first and third quarters, no fire drill occurred. Also, there was no fire drill on the second shift during the fourth quarter. Obviously, there should be further study to determine the cause for the compliancy issue vs. staffing deficiencies during third shift. Additionally, each department will have a safety monitor assigned to ensure the fire drills occur as per hospital policy. The safety monitor will complete a form documenting the staff involved in the fire drill, date, and time the drill took place and will keep a copy in the safety manual to be inspected monthly.

Other safety concerns that were identified during the PPR rounds include clutter in the hallways, smoke wall penetrations, master alarm panel for medical gasses was not tested, and the gift shop did not have the required 18” clearance from the sprinklers. The maintenance department manager will need to implement a corrective action plan and be held accountable for the discrepancies identified.

Additionally, the Moderate Sedation Monthly Audit of the Endoscopy Department shows some compliancy issues regarding pre-procedure events. Mallampati classification, ASA, Sedation plan documentation, and completion of reassessment are consistently below 90% for all four quarters. However, the actions that must occur during the procedure and post procedure rated at 90% or higher with regards to the Joint Commission recommendations for compliancy. Per the Joint Commission, compliancy should idealistically be 100%, therefore, the majority of the pre-procedure events are out of compliance and a corrective action plan to improve consistency must be implemented.

Patient falls continue to be a concern throughout the healthcare industry because many times the fall results in injury. Other concerns of patient safety that are addressed by the Joint Commission are related to pressure ulcers and ventilator associated pneumonia. The Intensive Care Unit had an increase in falls but no correlation was found between the numbers of falls to nursing care hours. However, ventilator associated pneumonia increased this year. Corrective actions were put into place to improve the VAP numbers. On the Oncology Unit, 3E, both falls and pressure ulcer rates decreased. There were no trends identified with falls and ulcers in relation to nursing care hours or overtime.

On 4E, patient falls and pressure ulcers increased when nursing care hours increased. To determine the causes of non-compliance, the committee should look into the events that occurred during the fourth quarter. While there are trends during the second and third quarter, the fourth quarter appears to have been when the majority of falls, pressure ulcers, and VAP’s occurred. Otherwise, hospital-wide, the trend seems to show a decrease in compliancy during the third quarter.


The Joint Commission depicts staffing effectiveness as ensuring a proper mix of expertise and numbers of proficient staff necessary to effectively provide for the needs of the patient population in a hospital setting. Although costs incurred due to staffing levels consume a considerable portion of the hospitals revenue, studies have shown that sufficient staffing has a direct effect on quality and safety. (Joint Commission, 2010) Dall, Chen, Seifert, Maddox, and Hogan discovered financial benefits for increasing nursing staff levels. They determined that nosocomial infections and hospital length of stays were decreased when there was adequate nursing staff available. They also determined that mortality rates decreased as a result of increased nursing staff. (Dall, 2009)

Nursing hours indicate the quantity and complexity of patients for each area in the hospital. In order to determine how many nurses and other nursing staff will be necessary to care for the patients, one must determine the nursing hours per patient day. This is calculated by comparing the amount of nursing staff providing care to the total number of patients requiring care.

Nightingale Community Hospital has combined staffing effectiveness with performance improvement in order to demonstrate sustained improvements throughout selected clinical units. The units selected are based on the clinical and human resource indicators such as patient population, historical staffing issues, and input from staff and existing data. Traditionally, the clinical indicators have been falls, falls with injury, pressure ulcer prevalence, and ventilator associated pneumonia (VAP). Additionally, the human resource indicators include overtime and nursing care hours. Although the Joint Commission has not directed specific staffing levels or ratios, hospitals and other organizations are expected to ascertain their own levels with regard to their experience and history.

Based on the data from 3E – Oncology, no trends were identified with regard to falls, falls with injury, pressure ulcer prevalence, nursing hours, or overtime indicators. In fact, 3E experienced a decrease in falls and pressure ulcers. This may be the result of the nursing staff focusing on these indicators due to their patient population. Also, increasing awareness, improving education, and providing a skin care representative has improved patient safety.

The Intensive Care Unit (ICU) experienced an increase in falls without regard to nursing care hours. However, the unit did show an increase in ventilator associated pneumonia events. This occurred during the month of September when nursing care hours decreased. Prior months showed an increase in overtime hours for nursing staff which caused fatigue and burnout to become noticeable later. Due to increases in both falls and VAP’s, corrective actions were implemented to reduce these statistics for the coming year.

The Unit, 4E, data proved just the opposite as this unit encountered increases in both falls and pressure ulcer prevalence. According to the date obtained regarding falls, it is apparent that nursing care hours showed a relational trend with falls. In other words, when the nursing care hours decreased, falls increased. In comparison, when nursing care hours increased, the falls rate decreased. Drastic increases in falls occurred during June, September, November, December and February. Nursing hours during this time averaged 15 hours per shift. It appears the overtime hours occurred as a result of the holiday season and therefore caused nursing burnout. Due to vacations, holidays, and absenteeism, nurses are often required to work overtime. This pattern is obvious again during the summer months when accommodations for vacations are necessary.

However, the opposite is true with regards to pressure ulcers vs. nursing care hours. When the nursing care hours increased, the occurrences of pressure ulcers increased as well. This is possibly caused due to increased overtime hours resulting in the fatigue and burnout. This is a perfect environment for errors or the potential to cause harm. A more extensive study in the nursing care hours must be implemented in order to establish an aggressive corrective action plan to reduce the occurrences of pressure ulcers and falls. If the study shows the nursing staff to be working overtime, additional staff may be necessary as part of the corrective action plan. Hiring additional nurses will improve patient care, result in decreased turnover rates, and lead to increased job satisfaction which will ultimately lead to positive outcomes in patient care.


Hiring and retaining an adequate number of competent nurses is the greatest challenge facing hospitals and other healthcare organizations. Nursing has to work with the human resources department to improve hiring procedures. Human resources should implement plans to recruit competent nurses with the skills and education necessary to provide the care Nightingale is known for. Human resources will perform an analysis to determine the best qualities for nursing candidates and will recruit according to that standard. Additionally, alternative plans for additional staffing during known periods of absenteeism such as vacations and holidays will be constructed. It is imperative that nursing coverage does not become impaired due to absenteeism.

In order to attract and retain the best nurses, Nightingale needs to improve the benefit package. Nurses have often stated that caring for their patients is a joy, but administrative duties, non-nursing activities, and poor staffing practices results in low job satisfaction. Increased job satisfaction in turn, results in improved patient care and increased positive outcomes. Studies have shown that unhappy nurses have unhappy patients.

Other strategies that Nightingale Community Hospital can implement are to encourage nurses to cross train in multiple units in order to fill positions in other units when staffing shortages occur. Inadequate staffing levels can cause considerable harm to the patients but is also a financial burden to the organization. Adverse events are more common when staffing levels are low which are associated with increased costs due to the need for more intensive nursing care. (Stanton, 2004) The Utilization Guide for the ANA Principles for Nurse Staffing suggests the use of patient classification systems. (Utilization guide for the ANA principles for nurse staffing, 2005)

Utilizing a patient classification system provides guidelines for difficult staffing issues by identifying processes and procedures for improved staffing. Organizations benefit by supporting nursing judgment regarding individual patient needs, incorporating sources that reinforce standards of nursing practice, encouraging nursing participation evaluating products that may be used in staffing decision making, and champion the use of patient classification systems.

Works Cited

Dall, T. C. (2009). The Economic Value of Professional Nursing. Medical Care, 97-104.

Joint Commission. (2010). Management of Human Resources. CAMH: Comprehensive Accreditation Manual for Hospitals, Hr-1 – HR-10.

Stanton, M. R. (2004, March). Hospital Nurse Staffing and Quality of Care. Research in Action. Rockville, MD, USA: Agency for Healthcare Research and Quality.

(2005). Utilization guide for the ANA principles for nurse staffing. Washington, DC: American Nurses Association.

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