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Research to evaluate the status and credibility of the infection control measures and preventive strategies by the Nightingale Community Hospital.

1. Abstract

The purpose of this research is to evaluate the status and credibility of the infection control measures and preventive strategies by the Nightingale Community Hospital. This evaluation and analysis will be conducted on the Joint Commission Accreditation Standards. Following is the summary and overview of the compliance of Nightingale Community Hospital with the JCA Standards. Furthermore, the paper will also develop and present a corrective action plan to ensure that the Nightingale Community Hospital abides by all the specified standards.

2. Executive Summary

For evaluating the infection control and prevention status of the Nightingale Community Hospital, the consultants for Accreditation Audit were consulted for providing a details review, analysis, and evaluation, by which a corrective action plan can be developed for the hospital in compliance with the Joint Commission Standards. One key area focused in this report is infection prevention and control measures. For accreditation and evaluation, the Surveillance Objective document will be used for comparative data analysis.

Based on the research, observation, and analysis, there are four main areas that need to be focused on infection prevention and control. First is Hand Hygiene as per the listing of the Joint Commissions Standards. This area is performing sufficiently for the Nightingale Community Hospital with an efficiency level of 92%. The minimum acceptable level is 90%. However, there are still certain areas that need to be controlled and assessed for infection control and prevention. Based on this concern, the following are the chosen Joint Commission Standards that will be referred for the evaluation of the status of infection control and prevention by Nightingale Community Hospital:

  • 07.01.01
    • Focus on using appropriate hand washing and sanitizing techniques for patients, nurses, and other involved staff.
  • 07.03.01
    • Focus on preventing multi-drug resistant organism infections by developing specific strategies for their control and prevention.
  • 07.04.01
    • Implementation of evidence-based practices for the prevention of blood-stream-related infections.
  • 07.05.01
    • Creation and establishment of a sterilized field specifically for surgical sites for the prevention of surgical infections.

3. Introduction

Healthcare-related infection is a standout amongst the most widely recognized confusions of health care administration. It is a genuine health danger as it prompts expanded patients’ dreariness and mortality, the length of doctor’s facility stays, and the expenses related to doctor’s facility remain. Successful infection counteractive action and control are vital to giving superb health care to patients and a protected working condition for those that work in healthcare settings. It is vital to limit the danger of the spread of infection to patients and staff in doctor’s facilities by executing a great infection control program. This report traces the wide standards and practices of infection Control that are fundamental for the aversion and administration of infection.

Infections in hospitals are a noteworthy well-being worry for both health care suppliers and the patients. Considering grimness, mortality expanded the length of stay and the cost, endeavors ought to be made to make the healing facilities as protected as conceivable by counteracting such infections.

These rules have been produced for health care staff required in quiet care inwards and basic care ranges and for people in charge of observation and control of infections in doctor’s facilities.

The standards of the grading of proposals appraisal, advancement, and assessment framework are utilized to manage the evaluation of the nature of confirmation from high to low and to decide the quality of suggestions. Every suggestion is sorted on the premise of existing logical information, hypothetical methods of reasoning, pertinence, and monetary effect. The task of solid or feeble is considered of more noteworthy clinical significance than a distinction in letter level of nature of proof.

Checking incorporates different parts of infection control hones. Simultaneous checking of the considerable number of viewpoints won’t be conceivable along these lines prioritization must be finished by the infection control group contingent on the need and circumstance. Observing process consistency is most critical to diminish the frequency of infections, anticipating multi-drug resistance to anti-microbial and shielding healthcare workers from getting the infection. The technique of checking ought to be received according to the institutional arrangement. Natural observation alongside microbiological reconnaissance has been asserted to diminish the infection rate. Adherence to hand hygiene is considered a standout amongst essential preventive activity.

3.1.Purpose and Objectives of the Accreditation Surveillance

Following are the main purposes of this report:

  • The objective of Nightingale Community Hospital is to build up an extensive Infection Control Program to guarantee that the doctor’s facility has forms set up to limit/wipe out the danger of Surgical Site Infections (SSI) and Healthcare-Associated Infections
  • The Infection Control Program at this healing facility fuses the accompanying on a progressing premise:
    • Observation/ID, counteractive action/control, and detailing of infections all through the clinic are not constrained to patients, representatives, or doctors concentrating on Nonsocial Infections
    • Nonsocial Infections: known as doctor’s facility obtained infections will be infections are not introduced at the season of confirmation but rather created through the span of remain.
      • Endogenous: the patient as of now has the infection at the season of confirmation short the signs/manifestations of such infection yet resistance brings down finished a course of stay and infection presents
    • Cross Contamination: understanding ends up noticeably infected while remaining in the healing facility by interacting with invective operators along these lines building up an infection.
      • Assess and screen the consequences of changes made
    • Ceaselessly alter systems and approaches as required
    • Select and execute the best systems to limit negative results
    • Isolate the infection source from whatever remains of the doctor’s facility
    • Remove any further course of transmission
    • Nightingale Community Hospital as of late had an audit uncovering inadmissible outcomes in the Surgical Site Infection (SSI) rates

4. Importance and Significance of Accreditation in Health Care

Accreditation is critical in a contemporary health care institution. In such a manner, it merits saying the way that, today, health care organizations can give health care services of the top notch (Greenfield et al. 2012). In any case, the conveyance of healthcare services needs significant financial resources that build the danger of attempts being made by healthcare organizations to convey healthcare services of low quality to spare cash. This is the reason the improvement of national guidelines of health care services has become vital, and the accreditation has been acquainted with the guarantee that health care organizations give health care services that meet national benchmarks (Greenfield et al. 2012). The foundation of the national principles of health care services is basic to keep up the high caliber of health care services and security of Americans (Greenfield et al. 2012).

In such a unique situation, the significance of accreditation can scarcely be underestimated because accreditation infers the arrangement of health care organizations with licenses and controls of working of health care organizations to meet the set up national guidelines of health care organizations (Smits et al. 2014). In such a manner, accreditation becomes an effective device for control over the execution of healthcare organizations and their capacity to meet national healthcare measures (Smits et al. 2014).

In the meantime, to lead the accreditation, it was important to present organizations that accredit health care organizations. In fact, there are various organizations that accredit oversaw care organizations in the US (Smits et al. 2014). Every one of these organizations and programs goes for the arrangement of exclusive expectations of national health care organizations. The fundamental purpose of working organization accrediting health care organizations is to keep up the high caliber of health care services being conveyed to patients (Greenfield et al. 2012).

Then again, the presence of diverse organizations giving accreditation to healthcare organizations raises the issue of the elaboration of national guidelines of health care organizations (Jeong, Oh & Chun, 2915). Now, numerous organizations create diverse strategies, which are hard to meet national health care principles (Jeong, Oh & Chun, 2915). In such a way, the elaboration of national health care norms ought to be kept up by various accreditation organizations.

Accreditation is described as a procedure by which a fair-minded organization will audit a company’s operations to guarantee that the company is leading business in a way reliable to national benchmarks (URAC, 2007). It ought to be called attention to that accreditation is principally intended to give employers and purchasers a chance to recognize health plans given quality (Jeong, Oh & Chun, 2915). It ought to be called attention that the quality infers the quality of services as well as the quality of the state of work of employees. Moreover, accreditation targets a healthy environment for employees, as well as it, should furnish shoppers with solid items and services which are secure for human health since it builds up national health benchmarks that health care organizations on the neighborhood level ought to meet (Han, 2012).

Clearly, accreditation is of foremost significance, particularly in the cutting-edge age in light of the fact that the developing worries of individuals about their health, which however are not only the result of their regular craving to lead a healthy way of life, yet they are additionally the result of target elements (Han, 2012).

Therefore, it is critical to executing such components as accreditation to guarantee the health quality of service and items conveyed by companies to clients and also secure the work environment (Yeun, 2013). In the meantime, the usage of accreditation is insufficient. Furthermore, it is important to give intensive control over its satisfaction. For this reason, the Joint Accreditation Commission was made (Yeun, 2013). Essentially, this commission focuses on the accreditation of many sorts of health care organizations (Yeun, 2013).

Subsequently, considering all previously mentioned, it is conceivable to presume that accreditation assumes a critical part in the life of the present-day society since it adds to the foundation of the national health care guidelines in various organizations working in various parts of the patients that furnish Americans with health care services of higher quality (Yeun, 2013).

The procedure of accreditation is imperative for operational examination and quality change in the health division. It is finished by non-governmental agencies separated from the healthcare organization and assesses the capacity of that organization to meet an arrangement of guidelines intended to enhance the quality of healthcare (Han, 2012). There is have to separate the accreditation procedure from licensure, which is a non-intentional process done by an outfit of government that assesses if an individual has accomplished the level of competency that is important for the sensible assurance of the welfare, security, and general health and after that gives the authorization to take part in an occupation (Han, 2012).

Subsequently, the accreditation of the healthcare organization is imperative because the healthcare services rely upon the accreditation of the healthcare organization and its capacity to give healthcare services to the great (Han, 2012). What is implied here is the way that the fact of the matter is to give health care services of a high caliber and keep up the high caliber of health care services to meet national measures (Han, 2012). Truth be told, the accreditation of Nightingale’s health care organization infers that one may trust to my health care organization and they can be sure of the quality of health care services being conveyed.

5. Infection Control in Nightingale Community Hospital

Currently, the Nightingale Community Hospital has implemented its infection control and prevention mechanisms with a specific focus on surveillance, monitoring, minimization of instances, reduction in cases, and elimination of the risks of infection. For this purpose, their two core policy standards are NPSG 07.01.01 which focuses on hand sanitation, and NPSG. 07.03.01 that focuses on the implementation of evidence-based practices to control the multi-drug resistant organisms for the control of associated infections. Furthermore, the implementation of NPSG.07.04.01 has also ensured the prevention of bloodstream-related infections while NPSG.07.05.01 is referred for the sterilization of surgical sites. The purpose of this report is to ensure that the implementation of these standards is as per the required efficiency level for the Nightingale Community Hospital. Other than these, the environmental concerns and issues in the Nightingale Community Hospital will also be evaluated to ensure that no secondary factors are contributing to the spread of infections.

5.1.General Impact and Incidence of Infections in Health Care Institutes

Infection Control is an important medical procedure that focuses on the prevention of nosocomial and health care-associated infections. It is a practical domain of epidemiology.

Hospital-based infections are a noteworthy well-being sympathy toward both health care providers and patients. Considering the severity, mortality, delayed stay, and the cost, efforts, and measures must be made to make the hospitals as sheltered as would be prudent by preventing such infections (Monistrol et al. 2012).

Consistently, lives are lost on account of the spread of infections in hospitals (Monistrol et al. 2012). Healthcare laborers can find a way to prevent the spread of infectious maladies. These steps are a piece of infection control. Proper hand washing is the best approach to prevent the spread of infections in hospitals (Monistrol et al. 2012). On the off chance that you are a patient, don’t be hesitant to remind companions, family, and health care providers to wash their hands before drawing near to you (Monistrol et al. 2012).

It is essential, however frequently less perceived and less supported, as part of the infrastructure of health care (Monistrol et al. 2012). Infection control and hospital study of disease transmission are likened to general health hone, rehearsed inside the limits of a specific health-care conveyance framework as opposed to coordinated in society all in all (Tao et al. 2014). Infection control addresses factors identified with the spread of infections inside the healthcare setting, including prevention, checking and examination of exhibited or associated spread with an infection inside a specific healthcare setting, and administration (Tao et al. 2014). It is on this basis that the basic title being embraced inside health care is infection prevention and control (Tao et al. 2014).

Hands are the most widely recognized vehicle for transmission of living beings, and “hand hygiene” (Monistrol et al. 2012) is the absolute best method for preventing the even transmission of infections among hospital patients and health care personnel (Tao et al. 2014). Besides, Sterilization is a process planned to murder all microorganisms and is the most elevated amount of microbial execute that is conceivable (Tao et al. 2014). Sterilizers might be heating just (Tao et al. 2014).

Adequacy of the sterilizer is resolved in three ways (Krein et al. 2012). In the first place, mechanical pointers and gauges on the machine itself demonstrate the proper operation of the machine (Krein et al. 2012). Second heat sensitive pointers or tape on the sterilizing sacks change shading which shows proper levels of heat or steam (Krein et al. 2012). Furthermore, the third is organically trying in which a microorganism that is very heat and synthetic safe is chosen as the standard test (Krein et al. 2012). If the process murders this microorganism, the sterilizer is thought to be successful (Krein et al. 2012).

Sterilization, if performed properly, is a compelling method for preventing bacteria from spreading (Krein et al. 2012). It ought to be utilized for the cleaning of restorative instruments or gloves, and any medicinal thing that comes into contact with the circulatory system and sterile tissues (Krein et al. 2012).

Personal protective equipment (PPE) is a specific dress or equipment worn by a specialist for protection against a peril (Monistrol et al. 2012). The danger in a health care setting is an introduction to blood, salivation, or other bodily fluids or pressurized canned products that may convey infectious materials, for example, Hepatitis C, HIV, etc. (Tao et al. 2014). PPE prevents contact with a possibly infectious material by making a physical obstruction between the potentially infectious material and the healthcare laborer (Krein et al. 2012).

Following these procedures and standards, Hospital-based infections can be cured and prevented efficiently without much exposure.

9. References

Greenfield, D., Pawsey, M., Hinchcliff, R., Moldovan, M., & Braithwaite, J. (2012). The standard of healthcare accreditation standards: a review of empirical research underpinning their development and impact. BMC health services research, 12(1), 1.

Smits, H., Supachutikul, A., & Mate, K. S. (2014). Hospital accreditation: lessons from low-and middle-income countries. Globalization and health, 10(1), 1.

Jeong, S. Y., Oh, H. S., & Chun, H. K. (2015). Analysis of the Status of Infection Controls after Application of the Healthcare Accreditation System. The Korean Journal of Health Service Management, 9(4), 33-49.

Yeun, Y. R. (2013). The impact of healthcare accreditation on patient safety and quality, job satisfaction and organizational commitment: About a general hospital. Journal of the Korea Academia-Industrial Cooperation Society, 14(4), 1820-1829.

Han, S. W. (2012). The era of healthcare accreditation. Journal of the Korean Medical Association, 55(1), 5-6.

Krein, S. L., Kowalski, C. P., Hofer, T. P., & Saint, S. (2012). Preventing hospital-acquired infections: a national survey of practices reported by US hospitals in 2005 and 2009. Journal of general internal medicine27(7), 773-779.

Tao, X. B., Qian, L. H., Li, Y., Wu, Q., Ruan, J. J., Cai, D. Z., & Peng, H. (2014). Hospital-acquired infection rate in a tertiary care teaching hospital in China: a cross-sectional survey involving 2434 inpatients. International Journal of Infectious Diseases27, 7-9.

Monistrol, O., Calbo, E., Riera, M., Nicolas, C., Font, R., Freixas, N., & Garau, J. (2012). Impact of a hand hygiene educational programme on hospital‐acquired infections in medical wards. Clinical Microbiology and Infection18(12), 1212-1218.



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