...WGU AFT2 RAFT2 (Accreditation Audit) MBA Graduate Programe - Complete Course All 4 Tasks http://www.homeworkminutes.com/question/view/41054/AFT2-RAFT2-Accreditation-Audit-WGU-MBA-Graduate-Program-Complete-Course AFT2 Accreditation Audit Task 1 1. The purpose of this executive summary is to outline the current status of compliance of the organization for the priority focus area of communication, namely the standard UP.01.01.01 which is named the “Conduct a Pre-procedure Verification Process” as noted by the Joint Commission standards. A.2. The primary area of focus I chose to review was the communication aspect. I feel that communication is vital in any business, especially health care. Clear communication improves patient care and the quality of care. This is evident when time is taken to verify a patient or a procedure. When things go wrong due to misidentification of a patient, not only does that cost time and money for the patient as well as the extra burden of having that wrong fixed, but it also costs the hospitals too. Their costs are increased by trying to fix the issue and then legal issues to follow. The best way to avoid any mistake and/or injury is to adopt a more vigorous verification system. AFT2 Accreditation Audit Task 2 A.1. An unexpected occurrence that involves serious bodily or psychological harm including death or the risk leading to these is known as a sentinel event. (Sentinel event, 2013) A.2. Several people were...
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...Accreditation Audit: AFT2 task 2 1 Accreditation Audit: AFT2 Task 2 Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process. Accreditation Audit: AFT2 task 2 2 Analysis of Key Components RCA: Child Abduction Please note that the root cause analysis and action plan must show evidence of an analysis within the key components as outlined on the root cause analysis matrix for the specific type of event. An area on the matrix that may not have an identified process breakdown should still be summarized to determine that the component was evaluated. Brief description of event Briefly summarize the circumstances surrounding the occurrence including the patient outcome (e.g., death, loss of function). A 3-‐year-‐old female pediatric patient...
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...Executive Summary of Accreditation Audit June 2012 I prepared and reviewed an accreditation audit for Nightingale Community Hospital to organize and ensure compliance with Joint Commission standards for our hospital. We are preparing for a site visit that should occur within the next 13 months. I have reviewed the current compliance status of our hospital and will explain our corrective action plan that will ensure compliance with the Joint Commission standards for the focus area of communication. An accreditation audit was performed by Carl Anderson, Director of Quality. We were only in 100% compliance in December throughout the year in one of the priority focus areas of the Joint Commission standard: Communication; Standard: UP.01.03.01; A time out is performed before the procedure. See chart below: This is the universal protocol for preventing wrong site, wrong procedure, and wrong Patient Surgeries. In evaluating this, I must review all standards that go hand in hand with the time-out standard; per Nightingale Community Hospital policy, Site Identification and Verification (Universal Protocol). I will address the elements of performance for all three: UP.01.01.01; Conduct a preprocedure verification process. UP.01.02.01; Mark the procedure site, and UP.01.03.01; A time-out is performed before the procedure. I will then address the items that are not addressed in Nightingale's policy in my corrective action plan and add any updates. (Commission, 2012) Standard...
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...Accreditation Audit Task 1. A1. Communication, this is the key focus area that is evaluated in this summary. Communication is a key focus area of the joint commission audit and is also a key area in which Nightingale Community can make enhancements. Communications must be a two way free flow of information. The information exchanges occur between providers, staff, and patients or clients. This was an area that needed improvement was noted in the previous accreditation audit. Some noted prior issues from 2 years ago included patient and family education and information not being properly disseminated to the nursing staff. These are areas where we have targeted and currently meet. Some areas that we continue to work on are as follows. We currently need to address our time out policy. During the last year there were three months that Nightingale Community did poorly in this area. We must make sure that the time outs are not only conducted properly but more importantly documented in the patients chart. If the time out is not properly documented in the patients chart the organization will not receive credit, it will be as though it never occurred. We must make sure that all providers and clinical staff have appropriate training and training materials provided for the time out policy. We will continue to quantify our efforts monthly in this key area. We as an organization must make this goal monthly. Critical results are an issue of concern for the organization. Critical results...
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...Accreditation Audit AFT2 Task 1. Herman Big Mawanda Western Governors University Contents COMPLIANCE STATUS. 3 PLANS OF COMPLIANCE 7 JUSTIFICATION 8 BIBLIOGRAPHY 10 Nightingale Community Hospital provides leadership in quality health services. Its core values focus on safety, community, teamwork and accountability with a vision of being a hospital of choice for all and a mission to create a healing environment with a passionate commitment to health care excellence. This executive summary of the accreditation audit is presented to the senior leadership to outline the compliance, plan of compliance and institution of the hospital under the reviewed focus area of Information Management as per the Joint Commission Standards. COMPLIANCE STATUS. The Joint Commission Standard IM 02.02.01 requires that the hospital effectively manages the collection of health information. Nightingale Community Hospital is in compliance with this standard under its patient care policy which specifies prohibited abbreviations. Its policy states that the use of abbreviations and symbols in the medical record is discouraged to prevent errors; as these can be associated with misinterpretation resulting in medical errors, and patient harm. In case the intended meaning of the abbreviation or symbol in the context of a specific order is not clear, the ordering practitioner must be contacted for clarification. This procedure demands that the elements of performance under IM 02.02.01 of the...
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...Executive Summary Accreditation Audit- Task 1 Maggie Miklos January 25, 2014 Executive Summary At Nightingale Community Hospital (NCH) one of our core values is to provide superior service and outstanding clinical care as noted in our safety statement. We welcome The Joint Commission (TJC) to survey our facility on a triennial basis to ensure compliance with their established standards and Priority Focus Areas: Infection control, Communication, Medication Management, and Information Management. In anticipation of the unannounced site visit, I have reviewed our current state of compliance for gaps in the Communication focus area and have prepared actions to close the gaps to ensure compliance. To gauge NGH’s compliance in the Priority Focus Area, Communication, I have reviewed the following Universal Protocol Standards depicted in TJC Handbook. This protocol “…was created to address the continuing occurrence of wrong site, wrong procedure and wrong person surgery and other procedures in Joint Commission accredited organizations” (Joint Commission, 2013). Within each standard our facility must meet the Elements of Performance criteria. The three standards I will be reviewing are: UP.01.01.01: Conduct a preprocedure verification process. (Commission 2013) UP.01.02.01: Mark the procedure site. (Commission 2013) UP.01.03.0: A Time-out is performed before the procedure. (Commissions 2013) The rationale...
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...compliance status of the healthcare facility. Nightingale Community Hospital is compliant with The Joint Commission standards except the following areas: Accreditation function of environment of care and life safety, it was documented that more than 3 smoke wall penetrations were found on the 1st floor and one on the 4th floor. The hospital is to minimize the potential for harm from fire, and smoke (TJC, 2013). A review of documentation showed appropriate ILSM was not initiated during 3 construction projects this put employees and patients at risk. Education of fire safety equipment should have been completed before the project. The gift shop did not have the required 18 inch clearance from the sprinklers. All sprinklers must have at least 18 inches below and around of clearance for The Joint Commission standards. Review of department documentation shows that the master alarm panel for medical gasses was not tested annually per policy. This is a policy written by the hospital that is not being met. They are to follow the policies that they set for themselves. The Fire Drill History Report showed that the fire drill process is not adequate and does not meet standards. Quarterly fire drills are to be conducted as regulated by the Life Safety Code (TJC, 2013). Clutter was found in the hallways of 3E, 4E, OR and telemetry this could restrict people from leaving the floor safely in case of fire or smoke. Accreditations function of Nursing Leadership it was discovered that Nurses on...
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...organization and for my professional & personal growth. STRENGTH • Very pleasant, helpful and caring nature • Excellent communication skills • Excellent planning and problem solving skills • Able to take responsibilities • Proficient with spreadsheet • Punctual PROFESSIONAL EXPERIENCE • Presently working in India’s 1st & World’s 4th Largest Healthcare Consultancy Six Sigma Star Healthcare Pvt. Limited, Delhi as a Principal Consultant. • Worked in JJ Institute of Medical Sciences (Jeevan Jyoti Hospital), Bahadurgarh as a Principal Consultant (Quality). • Worked in Mayom Hospital (125 beded Multi-specialty Hospital), Gurgaon, as a Manager -Operations. • Worked in Artemis Hospital (NABH Accredited), Gurgaon as an Associate- Patient Care Services. JOB RESPONSIBILITIES- As a Principal Consultant- Providing Consultancy related to Quality Improvement, Hospital Planning & Designing, Medico Legal Aspects, Education, etc. • Assessing and identifying existing status and gaps using NABH, NABL, JCI and other standards • Conducting work shop for creating awareness among employees in all levels of the hospital • Developing policies and systems in the entire process of the hospital for filling the gaps • Assistance in preparing all documents for the NABH accreditation including manuals, protocols, policy etc • Advice for Infrastructure up gradation • Assistance in fixing minimum competency of...
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...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 client’s 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 hospital’s 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 patient’s 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...
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...Accreditation Audit Task 1 Western Governors University A. Compliance Status Nightingale Community Hospital is not-for-profit, acute care hospital that houses 180 beds. Nightingale provides services in many areas such as general medicine, critical care, emergency services, oncology, cardiology, etc. Nightingale has four core values: safety, community, teamwork, and accountability. Nightingale’s vision is that patients, employees, physicians, volunteers, and community choose Nightingale’s as the hospital to receive care or to seek employment. To create a healing environment, with a passionate commitment to healthcare excellence is the goal of Nightingale. The next anticipated Joint Commission visit is about 13 months away. Over 20,000 health care organizations in the United States are accredited and certified by the Joint Commission. To receive accreditation from the Joint Commission is recognized nationwide as a symbol that certain performance standards of quality have been reached. A three-year accreditation cycle is standard for all member health care organizations. A two-year accreditation cycle is standard for laboratories. The Joint Commission provides the organization’s accreditation decision, the date the organization was awarded accreditation, but it does not provide the organization’s findings public. There are four Joint Commission focus areas for Nightingale and they are: Information Management, Medication Management, Communication, and Infection Control...
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...Regulatory and Compliance: Hospital Communication and Wrong Site Surgery Prevention March 21st, 2014 Accreditation Audit Regulatory Audits and Compliance Hospital Communication and Wrong Site Surgery Prevention Background: Wrong Site Surgery is costly and horrifying experience for the patient, the physician and the hospital. It is considered a preventable medical error. In 1999, the Institue of Medicine report, To Err is Human states that “clinicians were unaware of the number of surgery-associated injuries, deaths, and near misses because there was no process for recognizing, reporting, and tracking these events.” (LT Kohn, 2000) Physicians and nurses do not wake up desiring to harm patients, in fact, they take an oath to do not harm, but humans make mistakes. Unlike a mechanic or a car salesman, nurses and physicians are caring for people, and their mistakes can be detrimental to the patients to the point of death. The reasons safety nets need to be put into place to ensure compliance for the patient are obvious, but additionally for the physician and facility the cost of wrong site surgery (WSS) can be detrimental “State licensure boards are imposing penalties on surgeons for WSS, and some insurers have decided to no longer pay providers for WSS or wrong-person surgery, nor for leaving a foreign object in a patient’s body after surgery. Surgery performed on the wrong site or wrong person has also often been held compensable under malpractice claims. Seventy-nine...
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...2013). The Joint Commission began in 1910 as an evaluation process called “the end result system of hospital standardization” to determine successful treatments of patients. Over the next 40 years, The Joint Commission evolved into a collaboration system. In 1951, several stakeholders, such as the ACP, the AMA, the AHA, and the CMA, join to create the Joint Commission on Accreditation of Hospitals (JCAH). This organization serves to provide voluntary accreditation for health care agencies. This accreditation system inspires health care organizations to “provide safe and effective health care of the highest quality and value” (The Joint Commission, 2013, para. 3). Therefore, by evaluation and accreditation of more than 20,000 health care organizations, JCAHO is the nation’s oldest and largest accrediting agency in health care. Thus, to earn and maintain JCAHO’s “Golden Seal” of approval, an organization must submit to an on-site survey every three years. Structure and Role The source of JCAHO’s authority comes from a government of 32 members on the Board of Commissioners. Among the members are administrators, physicians, nurses, quality experts, educators, and labor representatives. These members bring a diversity of experience in public policy, business, and health care. The Joint Commission’s scope of service includes the active monitoring of regulatory activities to identify opportunities for improvement, accreditation, and certification. This service provides a standard of...
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...Governor’s University: Accreditation Audit Running Header: Task I 2 Executive Summary Nightingale Community Hospital is committed to providing quality care and aims to be the first choice hospital for patients in the community. Four core values represent the passion Nightingale has for excellence: Safety, Community, Teamwork and Accountability. The goals of the hospital are to uphold an atmosphere of healing, promote the benefits of health, and to provide a compassionate experience for all. Overview In order to reach the aforementioned goals, values and commitments, Nightingale Community Hospital must be in compliance of regulatory agencies which outline specific, goaloriented sets of standards. The Joint Commission is one such agency that provides assistance and support to health care facilities to ensure that certain standards are met, education for implementing new standards and feedback of current healthcare practices as part of the accreditation process. According to Facts about Hospital Accreditation (2014), the “Joint Commission standards address the hospital’s performance in specific areas, and specify requirements to ensure that patient care is provided in a safe manner and in a secure environment (p. 1).” This agency uses a Priority Focus Process methodology to identify areas within healthcare organizations which have a significant impact on patient safety and quality of care. One of these areas that Nightingale Community Hospital would like to focus on...
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...Accreditation Audit Task 2 Sentinel Event Western Governors University Accreditation Audit Task 2 Sentinel Event Nightingale is a well establish Community Hospital, which has been servicing the community by providing excellent, and compassionate healthcare provides for their patients’ needs. There values statement pledge to themselves and the community, is a commitment to four core values the first being Safety with the quote “We put our patients first”. A1 Sentinel Event As defined by the Joint Commission (2014) a sentinel event is an unexpected occurrence involving death, or serious physical, psychological injury, or the risk thereof. With this said Nightingale community Hospital recently experienced a sentinel event involving the possible abduction of a pediatric patient. As per reported, September 29th a three year old patient come to the hospital for a surgical procedures, accompanied by her mother. During the registration portion of the process the mother completed all the registration paperwork that was required. Along with authorization document, the patient was then directed to the pre-op area where the pre-op assessment was completed. It was at this time the mother informed the per-op nurse that she had several errands she needed to run while her daughter was in surgery, but she would be back to pick her up. The mother asked that if she had not return by the time her daughter surgery was completed to please call her mobile phone, and gave the pre-op nurse...
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...WGU Accreditation Audit: RAFT Task 1 Nightingale Community Hospital (NCH) has thirteen months until their next Joint Commission audit. This report will evaluate Nightingale Hospital’s compliance in The Priority Focus Area of Communication using the Universal Protocol Standards from the Joint Commission Handbook. “The Universal Protocol was created to address the continuing occurrence of wrong site, wrong procedure and wrong person surgery and other procedures in Joint Commission accredited organizations” (Joint Commission, 2013). The Standards of Universal Protocols (UP) are: UP 01.01.01Conduct pre-procedure verification process UP 01.02.01Mark the procedure site UP 01.03.01Perform a Time-Out before the procedure. To determine NCH compliance, hospital documentation was used for comparison with the Joint Commission, Elements of Performance. The following chart specifies which documents were used to show areas in need of improvement. Nightingale Community Hospital Documentation| Compared with|(UP) Elements of Performance| Pre-Procedure Hand-Off check listSite Identification and Verification (UP) (Sub heading) Preoperative Verification Process||UP.01.01.01Description # 1Description # 2| Site Identification and Verification (UP) (Sub heading) Marking the Operative/Invasive Site||UP. 01.02.01Description # 5| Safety Report Time-Out Graph||UP. 01.03.01Description #1 | Compliance Status Executive Summary and Findings according to the Joint Commission, Elements of Performance...
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