RAFT Task 1 Accreditation Case Study

Name: Marissa D. Jose

Instructor: Dr. Linda Joyce Gunn, CPHRM

Course title: AFT2 Accreditation Audit

Name of institution: Western Governor University

Current Compliance Status for Infection Prevention and Control 1. Commission Standard: Infection Investigation/Identification Recently the hospital implements preventing spread of Infection. The hospital has a successful framework for controlling the spread of infection and/or outbreaks among patients/clients, employees, physician, volunteers, students, and visitors. Identification and managing infections at the time of a clients admission to the hospital and throughout their stay are the critical aspects of the infection prevention and control program, in addition to subsequent renowned infection control practices while providing care. In the hospitals admission process, there are numerous ways to investigate, control, and prevent infections in the hospital setting, decides what procedures, such as isolation, should be applied to an individual client; and maintains a record of incidents and corrective actions related to infections. This process includes taking the patients history of infection, previous hospitalization, current diagnosis, and presence of draining wound, among others. During the health screening process, the hospital also ensures that the patient gets help from the right staff. Immediately the patient checks into the Nightingale Community Hospital, the symptoms are examined. This forms the basis of the treatment. In addition to the symptoms, laboratory tests are used to augment the diagnosis process. The hospital has a strict policy to screen the patient for infection within 24 hours upon admission. 2. Commission Standard: Compliance with Hand Hygiene In order to maintain accuracy of proper hand hygiene, the Nightingale Hospital has a strict policy that before and after performing procedures, before and after touching

the patients, after touching the body fluids/bloods, the staff shall wash and dried up his or her hands consistent with sound hygienic practices. This approach is also useful in minimizing the spread of disease and for protection and safety of an individual. For instance, the hospital implements consistent use by staff the proper hand washing practice and techniques which are critical to preventing the spread of infections. It is essential for staff to practice the proper hand washing technique with disinfectant soap and water. Hospital also encourages staff the use of alcohol based hand rubs used in place of proper hand washing techniques. In addition, gloves or the use of baby wipes are not a substitute for hand hygiene. The hospital is currently struggling with the proper hand washing practice. During the previous year, it has been determined objectively in several observational situation of hand hygiene behavior, the hospital had 30 occurrences for forgetting to perform hand hygiene within its records. This has increased to 60 during the current year the staff are not gelling in gelling out. This shows noncompliance to the commission standards of infection prevention and control plan. Although the Nightingale Community Hospital has an excellent policy for infection control, the implementation framework is not compliant with the commission standards for infection prevention. In the recent year, the hospital has more than 80 incidents of health practitioner not performing hand hygiene within its records. 3. Commission Standard: Infection Control Audit The hospital shows moderate compliance to this standard. This is for the reason that it performs an audit of infection control records every year. This is a necessary

approach towards maintaining the maximum standards of infection prevention and control plan. However, it does not have a framework for quarterly or half-year audits. PLAN FOR COMPLIANCE This corrective action plan seeks to develop a framework for enhancing the hospitals compliance to the joint commission standards of infection prevention and control plan. Even though the hospital shows compliance to some components of this focus area, some standards are in terrible need of an action plan. The successful execution of the action plan requires collaboration and support from the Nightingale Community Hospital which may involve the administrator, the medical director or his/her designee, the director of nursing, and other appropriate hospital staff as needed. As a result, the hospital should provide qualified Infection Prevention Coordinator, Surveillance, and Educators. Besides to the hospitals nursing practitioners and physicians are also significant stakeholders in the plan for compliance. Following is an evaluation of the corrective action plan for infection prevention and control in row with the three standards provided in the compliance statement. 1. Commission Standard: Infection Investigation/Identification Although the infection prevention and control plan system for Nightingale Community Hospital has an effective framework for screening patient from infection some weaknesses are evident. For instance, the hospital does not have a framework for maintaining an ongoing program designed to prevent and control infections. According the commissions standards on infection prevention and control plan, the infection control and prevention program must include documentation that Hospital

has considered, selected, and implemented nationally recognized infection control guidelines. This specification is vital in promoting the excellence of care among all patients. In order to enhance infection prevention and minimize the potential for transmission of infections the hospital can evaluate whether it needs to change process or practices. Nightingale Community Hospital has various approaches to gathering, documenting, and recording surveillance data. Important fundamentals of a surveillance process embrace use of standardized definitions and listings of the symptoms of infections, use of surveillance tools such as infection surveys and data collection templates, walking rounds throughout the hospital. For instance, the hospital should implement task method and/or outcome surveillance actions to classify infections that are causing, or have the probable to cause an outbreak. It is essential to conduct the data analysis to facilitate notice unusual or unforeseen outcomes and to conclude the efficiency of infection prevention and control practices. Additionally, document comments and observation related to the causes of infection and/or infection trends and implements measures to prevent the transmission of infectious agents and to reduce risks for device and procedure-related infections. This approach would play an integral role in strengthening the effectiveness of infection prevention at Nightingale Community Hospital. Small change in the infection prevention process can make a big difference in the quality of management outcome. 2. Commission Standard: Compliance with Hand Hygiene Hand hygiene is the most effective way to stop the increase of infection.

As we all know, hand hygiene noncompliance is a major cause of nosocomial infection. Hospital-acquired infections cause more than 98,000 deaths annually in the United States and are associated with increased cost and duration of hospitalization. In addition, it consumes scarce hospital resources, and thus presents a major challenge for clinical governance and maims and kills patients. (Cumming, K., April 2010) From the current compliance status, it is clear that hospital staff fails to understand the importance of hand washing, and it is evident that the hospital has not been attaining the commission standards on accuracy. Although the hospital has an excellent framework that encourages every staff to perform proper hand hygiene, several factors influencing noncompliance with hand hygiene is still very high. The bad practice is still prevalent within the institution. In order to forestall this drift the hospital should introduce a strict enforcement framework against inconsistent practice in hand hygiene. This concern is very vital that require a superior dedication from management to persuade this performance. Now it is the moment for an unambiguous standard to be set, that hands should be decontaminated before each patient contact. If such a policy is not in place or being followed, the trust concerned may be liable in the event of litigation. Such penalties will enhance the standards of accuracy while handling the patients. Consequently, compliance with the previous standard will form an excellent patient care. To increase compliance, everyone could keep watch over each other, and it recommended that patients should be encouraged to ask the staff to wash their hands. Training, education and forums are another perspective that would comprise the

corrective action plan. Educating nurses and other staff about the importance of their individual actions and proper hand hygiene can improve patient safety and create an organizational culture that promotes hygiene. Furthermore, the hospital should organize regular seminars and other interactive forums for its staff. Through these forums, the practitioners would gain the relevant skills and knowledge for practicing proper hand hygiene while handling the patients. However, effective communications will play a fundamental role and can tremendously improve patient safety. 3. Commission Standard: Infection Control. This is the final component of the corrective action plan. From the compliance report, it is unmistakable that the Nightingale Community Hospital does not have a structure for quarterly or half-year audits. This shows noncompliance to the commission standards on infection prevention. Although the hospital has a framework for annual internal audits, its mechanism for external audit is not efficient. In order to address this issue, the hospital should implement various changes. Initially, it is imperative for the association to outsource auditing services from an external firm. This will assist in forestalling instances of prejudice in the hospitals audit framework. The hospital must also institute an inclusive structure that facilitates for quarterly audits. This is crucial approach towards being compliant. Regular audits of infection controls are necessary towards recognizing probable flaws within the institutions infection prevention.

JUSTIFICATION
Infection Prevention and Control is very significant provision of care in the workplace procedures polices. We are for all time bounded by microorganisms and bacteria and these be capable of occasionally contribute to the development and spread of infections. Infections can be potentially extremely detrimental so it is significant to attempt and control and prevent the spread of infection. The Nightingale Community Hospital is not exclusion in line with this affirmation. In array to enhance the quality of health care services, the hospital must rationalize its structure for infection prevention and control plan. Additionally, poor system in infection prevention can increase Health care-associated infections (HAI) because they occur frequently, it can cause morbidity and mortality and represent a significant burden among patients, health-care workers and health systems. (Otaiza, F & Pessoa-Silva, C., 2009) With the poor Infection Prevention Program the Nightingale Community Hospital would be unable to maintain an effective and highest healthcare for the people in the community. This segment seeks to validate the choice of infection prevention standards in the case audit. 2. Minimization of Costs. Confirming and managing infectious outbreak standards for this case audit can be costly and time consuming for the Nightingale Community Hospital. An effective facility-wide infection prevention and control program can help to contain costs and reduce adverse consequences. An effective program relies upon the involvement, for the support, and knowledge of the facilitys administration, the entire interdisciplinary. Noncompliance in hand hygiene is associated with signicant

attributable hospital costs. Minimal improvements in compliance lead to substantial savings (Cumming, K., April 2010) Significant cost linked with Nosocomial and Methycillin Resistance Staphyloccocus Aureus have been extensively in print. Little is recognized, nevertheless concerning the definite expenses of individual behaviors that direct to these infections, such as noncompliance with hand hygiene during patient care. Quantifying the cost of hand hygiene noncompliance will provide clinicians, administrators, and patient advocacy groups with concrete data that can be used to improve the accountability of hand hygiene noncompliance among hospital workers. On the other hand, proper and consistent hand hygiene can enhance the companys quest to minimize operational costs. Consequently, inappropriate and inconsistency in hand hygiene would have negative implications on the hospitals operational costs and will put the hospital into dilemma and immediate jeopardy and worst will lead to hospital foreclosure. However, the organization will easily avoid such challenges if it complies with the three standards of infection prevention and control. The regular audits in infection control are also essential towards minimizing operational costs. Enhancing the Quality of Health Care. The hospitals process is to propose the paramount sufficient standards of health care to all patients. The presence of ineffective infection prevention and control plan frameworks might easily undermine this undertaking. Infection prevention forms the highest and most respected of treatment programs in any health care organization. It is therefore complicated for the Nightingale Community Hospital to rationalize the quality

of care without an effective infection prevention and control. The three standards of compliance in this audit are fundamental towards the enhancement of quality health care among patients. To begin with, the effective investigation and identification of a suspected infection from patients will enable the practitioner to make accurate treatment. This is fundamental towards boosting the patients well being. The augmentation of accuracy standards is critical towards maintaining patient safety. Patients safety should take priority of other considerations. This is why the hospital should comply with the infection prevention and control standard. The hand hygiene is also essential when it comes to handling patients and to improve the quality of care. The regular audits of infection control reports also provide as a significant constituent of the quality structure. In the occasion of any flaws, the hospital will institute sufficient meddling measures. As a result this will enhance the value of patient upshot. 3. Ethical Standards. The standards in this case study have momentous implications upon health care ethics in Nightingale Community Hospital. Progressively, effective hand hygiene is mandatory in any healthcare setting for the protection of the patients as well as the safety of all staff. The hospital strongly reckon that as consideration is alert on the dangers and issues that relate to infection control that everyone should inspect the daily ethical implications of providing care for patients and hospital personnel in relation to preventing and treating infections. If the institution does not preserve the required standards of infection prevention, it is indistinguishable to the infringement

of health care ethics. The hospital does not have inclusive guidelines for promoting the effective infection prevention standards while handling patients. The audit results will therefore form an efficient structure for the hospital to institute such framework. The three standards of infection prevention in this audit are also critical for decision making. Decent decision making is a vital aspect of consideration in any health care setting. The entire health care decisions should seek to uphold the patients wellbeing or health condition. If the hospital complies with these standards, it will extensively enhance the quality of decision making. Conclusion The accreditation case study encompasses an audit of infection prevention and control plan at the Nightingale Community Hospital. Three commission standards form the basis of the entire audit. These standards include the hospitals framework for preventing spread of infection, proper hand washing, and audit of infection prevention and control. From the audit, the hospital shows noncompliance in different aspects of the three standards. In terms of accuracy, the hospital is currently struggling with following the infection prevention and control plan. While handling patients, the hospital should establish a checklist for receptive information. The checklist will play a significant role in minimizing the instances of errors in preventing the spread of infection. Education plays a big part in the communication process. Nursing and other education resources in a hospital setting should be involved at the onset of plan development. (Ramsey, 2013) The hospital should organize regular seminars and other interactive forums for its staff. Through these forums, the practitioners would gain the relevant skills and knowledge for preventing

spread of infection. In summing up, infection control plans must be vigilantly developed, reviewed on a standard basis, and highly be communicated to everybody using the plan. These philosophies must be delivered by staffs who apply them as part of their daily routine, to eradicate the probability of a patient acquiring a Healthcare Associated Infection and patients should expect nothing less. It is therefore significant that everyone recognizes and embraces the principle that they individually and collectively have a responsibility to ensure that the National Standards for the Prevention and Control of Healthcare Associated Infections are met and actively enforced by the staff of Nightingale Hospital.

References Cumming, K., (April 2010) Hand Hygiene Noncompliance, Chicago The University of Chicago Press Otaza, F. & Pessoa-Silva, C. (2009). Core components for infection prevention and control programmes, Geneva Switzerland Gerberding, J. M.D., M.P.H. (2002) Centers for Disease Control and Prevention, Guideline for Hand Hygiene in Health-Care Settings: No. RR-16)