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Western Governors
University AFT2 – Task 4
AFT2 – Task 4
Abdul Wali Shahzad
Western Governors University
Dr. Austin Arenz
June 27, 2025
, A1. Compliance Status
The accreditation process facilitates detecting known and
unknown risks to patient safety and quality of care by conducting
meaningful assessments. It inspires healthcare organizations to provide
high-quality care and encourages them to improve their performance.
As the director of accreditation, I reviewed the records, previous audits,
trends, and files of the Nightingale
Hospital across all departments. I assessed its current status and
preparedness for the upcoming
Joint Commission audit. During my review, I compared the Hospital's
current status against all 18 Joint Commission standard focus areas and
found the Hospital noncompliant in 11 different areas.
Compliant Noncompliant
• Accreditation Participation • Medication Management
Requirements (APR) (MM)
• Human Resources (HR) • National Patient Safety
• Infection Prevention and Goals
Control (IC) (NPSG)
• Emergency Management • Environment of Care (EC)
(EM) • Life Safety (LS)
• Rights and Responsibilities • Leadership (LD)
of the Individual (RI) • Medical Staff (MS)
• Waived Testing (WT) • Medication Management
• Transplant Safety (TS) (MM)
, • Performance Improvement • Record of Care, Treatment,
(PI) and Services (RC)
• Provision of Care,
Treatment, and Services
(PC)
• Information Management
(IM)
• Nursing (NR)
1. Accreditation Participation Requirement (APR):
Compliant
This standard is assessed during the initial Joint Commission survey.
Nightingale Hospital was found to be compliant because it accurately
represents its accreditation status, programs, and services according to
the Joint Commission standards. The Hospital notifies the public it serves
about how to contact its management or report a concern about the
safety and quality of care of the individual (s). The Hospital is not
involved in false or misleading advertising about its accreditation status.
, 2. Medication Management (MM): Noncompliant
Medication management is an essential part of patient care. Incorrect
medicine or dose can cause serious harm. During the audit, I evaluated
and inspected different medical management processes such as
planning, selection and procurement, storage, ordering, preparing and
dispensing, administration, and monitoring and found the Hospital
noncompliant based on the following cases:
a. During my interview with a staff member on the 4E-1st floor, I
noticed that the nurse did not follow the range order policy, and,
in another interview with the ICU nurse, she could not explain how
the range dose policy is executed. This is a direct violation of the
Joint Commission standard MM 04.01.01, which states that "there
must be a documented indication for all ordered medications."
b. In another instance, during the PPR rounds in the OR, I found the
Propofol syringes unlabeled. This has a direct impact on patient
health care and is a violation of Joint
Commission standards MM.05.01.09 and NPSG.03.04.01
EMAIL:1
Western Governors
University AFT2 – Task 4
AFT2 – Task 4
Abdul Wali Shahzad
Western Governors University
Dr. Austin Arenz
June 27, 2025
, A1. Compliance Status
The accreditation process facilitates detecting known and
unknown risks to patient safety and quality of care by conducting
meaningful assessments. It inspires healthcare organizations to provide
high-quality care and encourages them to improve their performance.
As the director of accreditation, I reviewed the records, previous audits,
trends, and files of the Nightingale
Hospital across all departments. I assessed its current status and
preparedness for the upcoming
Joint Commission audit. During my review, I compared the Hospital's
current status against all 18 Joint Commission standard focus areas and
found the Hospital noncompliant in 11 different areas.
Compliant Noncompliant
• Accreditation Participation • Medication Management
Requirements (APR) (MM)
• Human Resources (HR) • National Patient Safety
• Infection Prevention and Goals
Control (IC) (NPSG)
• Emergency Management • Environment of Care (EC)
(EM) • Life Safety (LS)
• Rights and Responsibilities • Leadership (LD)
of the Individual (RI) • Medical Staff (MS)
• Waived Testing (WT) • Medication Management
• Transplant Safety (TS) (MM)
, • Performance Improvement • Record of Care, Treatment,
(PI) and Services (RC)
• Provision of Care,
Treatment, and Services
(PC)
• Information Management
(IM)
• Nursing (NR)
1. Accreditation Participation Requirement (APR):
Compliant
This standard is assessed during the initial Joint Commission survey.
Nightingale Hospital was found to be compliant because it accurately
represents its accreditation status, programs, and services according to
the Joint Commission standards. The Hospital notifies the public it serves
about how to contact its management or report a concern about the
safety and quality of care of the individual (s). The Hospital is not
involved in false or misleading advertising about its accreditation status.
, 2. Medication Management (MM): Noncompliant
Medication management is an essential part of patient care. Incorrect
medicine or dose can cause serious harm. During the audit, I evaluated
and inspected different medical management processes such as
planning, selection and procurement, storage, ordering, preparing and
dispensing, administration, and monitoring and found the Hospital
noncompliant based on the following cases:
a. During my interview with a staff member on the 4E-1st floor, I
noticed that the nurse did not follow the range order policy, and,
in another interview with the ICU nurse, she could not explain how
the range dose policy is executed. This is a direct violation of the
Joint Commission standard MM 04.01.01, which states that "there
must be a documented indication for all ordered medications."
b. In another instance, during the PPR rounds in the OR, I found the
Propofol syringes unlabeled. This has a direct impact on patient
health care and is a violation of Joint
Commission standards MM.05.01.09 and NPSG.03.04.01
