...Tracer Patient Audit AFT2 Accreditation Audit October 10th, 2014 Tracer Patient Audit With an audit by the Joint Commission (JC) in the near future, Nightingale Community Hospital (NCH) is performing a tracer patient survey to measure our compliance and identify issues that are in need of remediation. The practice of this type of survey tracks a patient’s care for the duration of their stay starting from the admission process and ending when they are discharged. This system allows us to assess our strengths and weaknesses concerning policy, procedures, and systems in place to provide quality care in conjunction with the standards set forth by the JC. Summary of Tracer Patient Audit Findings This particular survey was conducted concerning a patient that is a 67 year old female, presenting with fever and drainage approximately 5 weeks after an open hysterectomy. The tracer patient was subsequently admitted for a possible postoperative infection. The tracer patient then endured another surgery to treat the infection that started after the original surgery. The patient also received a central line which is used to administer long-term antibiotics. NCH is arranging to discharge the patient to go home with home health, with the aid of her husband, to help administer her antibiotic therapy after discharge. The audit of this particular patient’s care revealed areas that present an opportunity for correction and improvement. Specifically, the patient...
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...Jenny Windler Student ID: 000329547 Accreditation Audit (AFT2) Task 1 A. Compliance Status Nightingale Community Hospital is a complete and leading healthcare facility that believes in providing the best quality care to all of their patients. As part of Nightingale’s mission to put the patient first, the hospital must meet medication management standards set forth by the hospital and the Joint Commission. Medication management often involves the efforts of multiple services and disciplines. It is part of Nightingale’s policy that a patient’s information is accessible to a physician, pharmacist or nurse in the management of a patient’s medication. Nightingale Hospital has all the policies in place that the Joint Commission looks for to keep the hospital accredited. A1. Plan for Compliance In reviewing the safety of using medication associated with Anticoagulation Therapy, Nightingale Hospital needs some improvement. There was only one month out of the year that patients did not experience any adverse effects related to Anticoagulation Therapy. Numbers were high at the beginning of the year and tapered off by the end of the year, but Nightingale Hospital should be experiencing more months where there are no adverse events. In combination to the Joint Commission’s finding 2 years ago regarding the lack of documented evidence that the patient’s ability/readiness to learn, learning preference, or educational needs were assessed and documented in the file, we have much...
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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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...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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...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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...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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...Report covering investigation of asbestos found in one of Bolton Wanderers premises. This report is a result of thoroughly carried out research towards asbestos found in a roof of one of Bolton Wanderers premises. The report is divided into the following parts: General information about asbestos. Risk assessment. Future advice./ After care Removing asbestos The report also covers all relevant legislation and includes recommendations for future actions for all of the parties involved. General information about asbestos. The ‘Control of asbestos Regulations', (CAR), came into force on 13th November 2006. Regulation 4a says that ‘the dutyholder’, here, Bolton Wanderers, is required to manage asbestos in their non-domestic premises. (1*) Asbestos is a naturally occurring fibrous material that has been a popular building material particularly between 1950 and 1999. Asbestos and asbestos containing material in good condition is safe. Asbestos is only dangerous when it is in a loose form, damaged, disturbed or being worked on as this can release asbestos fibres into the air. If these fibres are breathed in over a long period of time, they may damage the lungs, and can lead to very severe diseases such as mesothelioma or lung cancer (2*). In recent cases two families have won ground-breaking claims (one of them for two hundred and forty thousand pounds) for compensation after loved ones died from cancer after exposure to "low level" asbestos on Merseyside...
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...EVALUATING A WEBSITE: JOINT COMMISSION CREDIBILITY Evaluation TJC’s website is published by very well known organization and ends in .org which makes it very appropriate for offering authority. The information throughout the website is very accurate and provides daily updates. There is a link that is labeled “Daily Update” that offers most recent news anywhere from the day of your search to as far back as a month ago. There is also a “Contact Us” link that offers a customer service phone number for general questions. This website does not appear to be biased and is produced by an organization that offers very important information in becoming accredited or certified without a source of funding impact. Information is clearly listed on the website and can be accessed directly. The website and graphics of the site load very quickly and all the links are functioning. As far a privacy and security, this does not seem to be an issue for just simply searching the website generally. There is no sign in required to search for organizations but there is an option to Log In or log in using a Guest Access Request. If you choose either option, it takes you to a secure website called Joint Commission Connect and also lists other key stakeholders the website is intended for. Credibility TJC recommends best clinical practices. Incorporation of best clinical practices into the baccalaureate critical care nursing curriculum is important. Best practices promote...
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...Association of Medical Assistants, offers a Certified Medical Assistant Certification for those who have obtained the required education through an accredited medical assistant program (American Association of Medical Assistants). The Medical Assistant’s professional Code of Ethics is a guide I can always refer back to when my ethical responsibilities are being tested, or when I am in doubt whether a certain situation is ethical or not. It is a reminder of why I choose this career, dedicating myself to the care and wellbeing of all people. For Medical Assistants, there are three certifying agencies available within the state of California, where I reside: American Association of Medical Assistants, where you can obtain a “NCCA” Accreditation (aama-nh.org), American Medical Technologists RMA certification, where you can obtain a AMT certification (amt1.com), and California Certifying Board of Medical Assistants where you can obtain a California Certified Medical Assistant (CCMA) certification (ccbma.org). The “Scope of Practice” determines the boundaries that a physician, or other medical professional practices. In entails the range of responsibilities and practice guidelines (medical-dictionary.thefreedictionary.com). The American Association of Medical Assistants determines this (aama.ntl.org). Three of the standards of professionalism that are based on the codes of ethics for Medical Assistants are: Seek to continually improve the knowledge and skills of the Medical...
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...Joint Commission Eligibility for Hospital Accreditation, the organization must be in the United States or its territories, or if outside the United States, is operated by the U.S. government or under a charter of the U.S. Congress. For all programs by law the organization has a facility license or registration to conduct its scope of services. The organization can demonstrate that it continually assesses and improves the quality of its care, treatment, and/or services. .The organization identifies the services it provides, indicating which care, treatment, and/or services it provides directly, under contract, or through some other arrangement. The organization provides services that can be evaluated by Joint Commission standards. If the organization uses its Joint Commission accreditation for deemed status purposes, the organization needs to meets the Center for Medicare and Medicaid Services. The organization must meet parameters for the minimum number of in patients/volume of services required for organizations seeking Joint Commission accreditation for the first time. A hospital that is seeking Medicare Certification and is new to The Joint Commission must have one active inpatient case at the time of survey. If the hospital’s Average Daily Census is 21 or more, or if the hospital is a specialty hospital (cardiac, orthopedic, or surgical), the hospital must be able to provide inpatient records for at least 10 percent of the average daily census, but not less than 30 inpatient...
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...knowledge in practical case studies. In addition, due to the dynamic nature of the primary markets, the programme emphasises current market practice and much use is made of market practitioners to discuss key areas. Candidates who gain this qualification therefore will have all the requisite tools to add value now to their company’s activities in the Primary Markets. As a second-level qualification the PMC syllabus requires that the candidate should already have some familiarity with: • Fundamental numeric skills, the time value of money, PV, yields and yield curves • The main debt market sectors, products and key players The academic content of the PMC is overseen by the ICMA Centre at the University of Reading, England. Accreditation The ICMA Primary Market Certificate...
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...be determined upon prior to construction of the facility. Cost estimate and budget planning are the first steps, which must be determined before the design of the facility. An implementation plan of the proposal from the preliminary phases of the plan of the facility through construction of the facility has to be arranged and charted. Regulatory requirements Health care facilities are required to follow the licensing regulations of their state in the design they use. Usually this is the 'Facility Guidelines Institute guidelines for design and construction of health care facilities' (Carr, 2010). The states require use of the codes in International Building and in addition, they need to be accredited by the 'Joint Commission on the Accreditation of Healthcare Organizations' (Carr, 2010). The regulations require compliance with the fire codes set by the National Fire protection Association and follow the standards set in NFPA 99 and NFPA 101 which guide safety within the facilities. The facilities must also follow the American with Disability Act since it is a public facility. They must follow OSHA regulations in setting up the design especially for their laboratory. Health facilities need to be...
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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 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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...------------------------------------------------- Task 1: Executive Summary Assessment Code: AFT2 Executive Summary: Nightingale Community Hospital Joint Commission Compliance Standards for Communication Focus Area Recently there has been much media focus on preventable medical errors. Any google search will produce a multitude of news articles that all report that preventable medical errors is now the third leading cause of death in the United States. Poor communication plays a role in most if not all of these errors. In fact the Joint Commission (2012) has published that an estimated 80% of serious medical errors involve miscommunication between caregivers during the transfer of patients. While communication errors are not the sole cause, they certainly contribute to the problem and must be a consideration in every patient safety program. One particular area of preventable medical errors involving communication errors that has received widespread media attention is wrong site surgery. Chassin (2013) reported that wrong site or wrong person surgery occurs an estimated 50 times weekly in the United States. This number is hard to judge exactly as not all states mandate reporting, but the fact remains that wrong site surgery continues to occur despite concerted efforts to prevent it. All hospitals to include Nightingale must continue to place emphasis on preventing these errors. Nightingale has wisely chosen to focus on this area for the upcoming Joint Commission...
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