...AFT2 Accreditation Audit – Task 2 Western Governor’s University AFT2 Accreditation Audit – Task 2 Nightingale Community Hospital is a healthcare facility that prides itself on being a hospital of choice within its community by being a leader in providing high quality healthcare. The first of Nightingale Community Hospital’s value statements addresses safety. A key aspect in providing safe patient care includes communication among caregivers. A1. Sentinel Event Nightingale Community Hospital recently experienced a sentinel event that involved the possible abduction of a 3 year old patient. As defined by the Joint Commission (2014), a sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. On September 14th a 3 year old patient came to the hospital for an outpatient procedure. She was accompanied by her mother. They first registered for the procedure and completed all required registration documents including authorization forms. The patient then went to the pre-op area to complete all pre-op assessments. At this time the mother informed the pre-op nurse that she had to take care of a personal matter with her son while her daughter, the patient, was in surgery. The mother gave her contact information to the pre-op nurse who then recorded it in her personal notebook. From the pre-op area the patient was then taken to the operating room. Both nurses and surgeons are present during the...
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...Sentinel Event Root Cause Analysis AFT2 Accreditation Audit October 4th, 2014 Sentinel Event Root Cause Analysis As defined by the Joint Commission (2014) a sentinel event is, “An unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. The phrase "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome” (Joint Commission, 2014). The sentinel event concerns a possible child abduction from a surgical unit within the Nightingale Community Hospital (NCH) on September 14th. A 3 year old patient was dropped off with a pre-op nurse for surgery. Prior to this the mother and child complete all necessary paperwork for surgery including appropriate authorization forms. The mother informed the nurse she had to leave the hospital and would return when her child would be released approximately 1 hour and 45 minutes later after the surgery and recovery period. The mother provided contact in case the child was ready for release earlier than the specified time frame. When the child was ready to be released the recovery nurse paged the mother, but the mother had not yet returned. Care of the child was reassigned to the discharge nurse. It was discovered that the father was in the waiting area and was then allowed to see the child. After 30 minutes had lapsed from the time the mother said she would return the discharge nurse elected to provide discharge...
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...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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...Running head: ACCREDITATION AUDIT- TASK 4 COMPLAINCE STATUS Joint Commission clearly explained that a Periodic Performance Review is as an assessment tool designed to help in assisting the healthcare organization contributes greatly in the improvement and monitoring performance all through the year. The periodic performance focuses more on the measures that has to do with patients safety and care and at same time given the facility for unremitting standards fulfillment. NCH is 100% compliance with most standards of Joint Commission in the following area; Emergency Management, Human resources, Infection Prevention and Control, Performance Improvement, Right and Responsibilities of the Individuals, Transplant Safety. During the inspection at the facility, the hospital was found to be non- compliant in this listed areas; Environment of Care, Leadership, Life Safety, universal protocol, Medication Management, Medical Staff, National Patient Safety Goals, Nursing, Record of Care, Treatment and Services, and provision of care During the PPR, the hospital was found with an increase cluster in the hallways, it is a fire hazard and a safety issue. The nurses are not familiar with verbal order procedures, using the range of orders that received and the abbreviations that are prohibited in the documents. From the trend, there are areas at which the hospital needs to implement proper education and audit. An action plan needs to be implemented by the administration to address the fallout...
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...OVERVIEW 1 2 CONTRACT REQUIREMENTS 1 2.1 Objectives Fulfillment 1 2.1.1 Business Objectives 1 2.1.2 Technical Objectives 2 2.1.3 Management Objectives 3 2.2 Assumptions and Constraints 3 2.2.1 Access Control 4 2.2.2 Authentication 4 2.2.3 HSPD-12 Personnel Security Clearances 4 2.2.4 Non-Disclosure Agreements 5 2.2.5 Accessibility 5 2.2.6 Data 5 2.2.7 Confidentiality, Security, and Privacy 5 2.3 Tasks/Sub-Tasks to Be Performed Related to Initiating the Service 6 2.3.1 Task 1: 6 2.3.2 Task 2: 7 2.4 Period of Performance 7 3 PERFORMANCE MANAGEMENT OF THE DELIVERED SERVICES 8 3.1 Modifications to Service Level Agreements 8 3.2 Changes to Key Performance Measures. 8 3.3 Quality Assurance Evaluation 8 3.4 Government Roles and Responsibilities. 9 3.4.1 Contracting Officer (CO) 9 3.4.2 Contract Specialist 9 3.4.3 Contracting Officer’s Technical Representative (COTR) 10 3.4.4 Other Key Government Personnel 10 3.5 Contractor Roles and Responsibilities 10 4 METHODS OF QUALITY ASSURANCE SURVEILLANCE 11 5 SECURITY REQUIREMENTS 11 5.1 Required Policies and Regulations for GSA Contracts 11 5.2 GSA Security Compliance Requirements 13 5.3 Certification and Accreditation (C&A) Activities 13 5.3.1 Certification of System 14 5.3.2 Accreditation of System 15 ...
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...Running Header: Task I 1 Task I Abigail M. Garcia Western 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...
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.... 3 II. NIST Risk Management Framework for FISMA ..................................................................... 4 III. Application Security and FISMA .......................................................................................... 5 IV. NIST SP 800‐37 and FISMA .................................................................................................. 6 V. How Veracode Can Help ...................................................................................................... 7 VI. NIST SP 800‐37 Tasks & Veracode Solutions ....................................................................... 8 VII. Summary and Conclusions ............................................................................................... 10 About Veracode .................................................................................................................... 11 © 2008 Veracode, Inc. 2 Overview The Federal Information Security Management Act of 2002 ("FISMA", 44 U.S.C. § 3541, et seq.) is a United States federal law enacted in 2002 as Title III of the E‐ Government Act of 2002 (Pub.L. 107‐347, 116 Stat. 2899). The Act is meant to bolster computer and network security within the Federal Government and affiliated parties (such as government contractors) by mandating information security controls and periodic audits. I. The Role of NIST in FISMA Compliance The National Institute of Standards and...
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...survey of information security professionals from around the world and are also based on the many different information security and assurance frameworks (ISO 27001/2, COBIT, ITL, etc.). The results of this survey were used in weighing the subject areas and ensuring that the weighting is representative of the relative importance of the content. The Security Policy and Standards subdomain focuses on creating organizational security activities and policies; assessing information security risk; and implementing and auditing information security management programs, information assurance certification programs, and security ethics. Watch the following video for an introduction to this course: Competencies This course provides guidance to help you demonstrate the following 3 competencies: Competency 427.3.2: Controls and Countermeasures The graduate evaluates security threats and identifies and applies security controls based on analyses and industry standards and best practices. Competency 427.3.3: Security Audits The graduate evaluates the practice of defining and implementing a security audit and conducts an information security audit using industry best practices. Competency 427.3.4: Certifications and Accreditations The graduate identifies and discusses the Information Assurance certification and accreditation (C&A) process. Course Mentor Assistance As you prepare to successfully demonstrate competency in this subject, remember that course mentors stand ready to help you reach...
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...Accreditation Audit: AFT Task 3 Western Governor’s University Abstract AFT Task 3 allows the examination of data from a patient while hospitalized at Nightingale Hospital and utilizes a tracer methodology to identify trends, patterns, and pertinent problems for healthcare improvement. We plan to develop a corrective action plan to address the organization’s improvement while maintaining compliance from a Joint Commission standard. Accreditation Audit: AFT Task 3 Nightingale Hospital is preparing to devise a mock tracer methodology to assess the organizations’ current compliance with Joint Commission Standards. A tracer methodology follows a patient through the course of care and evaluates all aspects of care (Joint Commission E-dition, 2014). This method allows a quick overview of a patient through the flow of a system in order to evaluate the effectiveness of the process flow. Our mock tracer patient is a sixty seven year old female whom recently underwent an open total abdominal hysterectomy secondary to menorrhagia and uterine fibroids. The patient presented back to the emergency room one week postoperatively with complaints of a subjective fever of 100.2 degrees Fahrenheit and incisional drainage described as yellowish-green in color. A CT scan of her abdomen was performed in the emergency room and revealed a peri-umbilical abscess. The surgical team was consulted and an incision and drainage of the abscess was performed. Infectious disease physicians determined...
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...1) The DoD Information Assurance Certification and Accreditation Process (DIACAP) is the United States Department of Defense (DoD) process to ensure that risk management is applied on Information Systems from an enterprise view. DIACAP is a DoD-wide standard set of activities, tasks and process for the certification and accreditation of a DoD information system that will maintain the Information Assurance posture throughout the system's life cycle. The Department of Defense Information Technology Security Certification and Accreditation Process (DITSCAP) is a process defined by the United States Department of Defense (DOD) for managing risk. DoD Instruction (DODI) 5200.40 establishes a standard DOD-wide process with a set of activities, general tasks and a management structure to certify and accredit an Automated Information System (AIS) that will maintain the Information Assurance (IA) posture of the Defense Information Infrastructure (DII) throughout the system's life cycle. DITSCAP applies to the acquisition, operation and sustainment of any DOD system that collects, stores, transmits, or processes unclassified or classified information since December 1997. 2) The Director of Central Intelligence Directive (DCID) 6/3 establishes the security policy and procedures for storing, processing, and communicating classified intelligence data in information systems. To achieve compliance with DCID 6/3, agencies must ensure that information is safeguarded at all times and that...
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...Assurance Certification and Accreditation Process (DIACAP) (a) Subchapter III of Chapter 35 of title 44, United States Code, “Federal Information Security Management Act (FISMA) of 2002” (b) DoD Directive 8500.01E, “Information Assurance (IA),” October 24, 2002 (c) DoD Directive 8100.1, “Global Information Grid (GIG) Overarching Policy,” September 19, 2002 (d) DoD Instruction 8500.2, “Information Assurance (IA) Implementation,” February 6, 2003 (e) through (ab), see Enclosure 1 1. PURPOSE This Instruction: 1.1. Implements References (a), (b), (c), and (d) by establishing the DIACAP for authorizing the operation of DoD Information Systems (ISs). 1.2. Cancels DoD Instruction (DoDI) 5200.40; DoD 8510.1-M; and ASD(NII)/DoD CIO memorandum, “Interim Department of Defense (DoD) Information Assurance (IA) Certification and Accreditation (C&A) Process Guidance” (References (e), (f), and (g)). 1.3. Establishes or continues the following positions, panels, and working groups to implement the DIACAP: the Senior Information Assurance Officer (SIAO), the Principal Accrediting Authority (PAA), the Defense Information Systems Network (DISN)/Global Information Grid (GIG) Flag Panel, the IA Senior Leadership (IASL), the Defense (previously DISN) IA Security Accreditation Working Group (DSAWG), and the DIACAP Technical Advisory Group (TAG). 1.4. Establishes a C&A process to manage the implementation of IA capabilities and services and provide visibility of accreditation decisions regarding the operation...
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...Assignment Task 1: The Advertisement - Term of contract, Misrepresentation or Mere Opinion? The initial issue is to classify the University of Kew’s advertisement that induced Brad to enter into a contract. If it constitutes a term of the contract, then contractual remedies would be awarded if there was a breach[1]. If it is a misrepresentation, then Brad would be provided with remedies for common law misrepresentation. However, if it is a mere statement of opinion or a prediction about the future, then it would have no legal consequence[2]. In JJJ Savage & Sons Pty Ltd v Blakney[3], the purchaser was denied damages, even when he was induced to enter into the contract by a non-promissory statement. Therefore for a statement to be classified as a term of contract, the parties must have intended it to be promissory in nature. Although the courts take into account a number of other factors to define the terms of contract[4], the advertisement is unlikely to be considered as a promise. Furthermore, had the advertisement not been included in the subsequent written contract, the parol evidence rule makes it even harder for Brad to pursue his right under contract. A misrepresentation is a false statement of fact, which allows Brad the right to rescind the contract[5]. Damages are also available if the university did not believe the truthfulness of the presentation[6]. However, the university’s liability regarding misrepresentation was excluded by the exclusion clause, which...
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...Review Questions for Chapter 7 – Security Management Practices Read Chapter 7 in the text, Study the Power Point Presentation and answer these Review Questions 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. What is benchmarking? What is the standard of due care? How does it relate to due diligence? What is a recommended security practice? What is a good source for finding such best practices? What is a gold standard in information security practices? Where can you find published criteria for it? When selecting recommended practices, what criteria should you use? When choosing recommended practices, what limitations should you keep in mind? What is baselining? How does it differ from benchmarking? What are the NIST-recommended documents that support the process of baselining? What is a performance measure in the context of information security management? What types of measures are used for information security management measurement programs? According to Dr. Kovacich, what are the critical questions to be kept in mind when developing a measurements program? What factors are critical to the success of an information security performance program? What is a performance target, and how is it used in establishing a measurement program? Answer: Performance targets are values assigned to specific metrics that indicate acceptable levels of performance. They make it possible to define success in the security program. 14. 15. List and describe the fields found in a properly and fully...
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...Continuous Accreditation Compliance - Task 4 AFT2 Accreditation Audit October 31st, 2014 Continuous Accreditation Compliance - Task 4 Nightingale Community Hospital (NCH), like many other health care facilities, uses a Periodic Performance Review (PPR) as an assessment tool that assists in examining performance on a consistent basis to ensure compliance with Joint Commission standards. A PPR concentrates attention on procedures, methods, and processes that contribute an environment that provides for proper care and emphasizes patient safety. NCH has shown to be 100% compliant with the majority of standards including: Infection Prevention and Control, Right and Responsibilities to Patients, Human Resources, Transplant Safety, Emergency Management, and Performance Improvement. During the last inspection NCH was found to be non-compliant in the following areas: National Patient Safety Goals, Record of Care, Environment of Care, Nursing, Treatment and Services, Leadership, Life Safety, Provision of Care, and Universal Protocol. Trending Areas of Concern The PPR revealed numerous issues in all areas of NCH. In order to address issues that affect patient safety and accreditation it is necessary to focus on issues that are found to be present in several areas of the facility. These patterns and trends of non-compliance often expose a weakness in policy, procedure, or training that needs to be addressed in order to ensure patient safety and accreditation compliance...
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