Compliant and non-compliant from the TJC list

This task is the longest and has two distinct areas for us to work on. The first area an overall review where we discuss what we did right and give a little scope to what we need to correct to a lesser extent. The second area is staffing issues. These may be new areas for some of you but actually it will be simpler than you think. You will need the artifacts from task 4 assessment area

  1. List all 18 compliant and non-compliant from the TJC list using the FSA sheet (I can send the list, or you can simply take it from the slides or the TJC site itself) Missing one of the 18 is the most common error remember the UP is part of the NPSG Leadership and Nursing are two separate EP Types).
  2. List all compliant EP’s again and say why each is important in a sentence or two.
  3. List one EP that is non-compliant and what we did wrong from the FSA sheet. This gives upper management an idea of the scope of the issues and lets them know that it is fixable.
  4. You will then choose two reports from the compressed files. My lecture I do Fire Drills and the Pain Management in the ER for instance. Here we look at poor performance over the course of several months.
  5. You are now ready to change gears and go into staffing, discuss what you see in the graphs, related to staffing patterns for 3E, 4E, and ICU when comparing ulcers and falls.
  6. Do you see any strong correlation between man hours and falls on 3E and ICU. If you think these falls are caused by manpower issues say so, if these falls are independent of staffing, then discuss briefly that the number of falls though not large there is room for improvement.

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