...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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...AFT2 Task 1 Christian Fisher Western Governors University AFT2 Task 1 A. Compliance Status During the last Joint Commission survey two years ago, there were several areas of deficiency surrounding the use of moderate or deep sedation or anesthesia. These noted deficiencies gave Nightingale Community Hospital the opportunity to revamp and strengthen our procedures in all areas of peri-operative services. These include the Main OR, CVOR (Cardiovascular OR), Interventional Labs (Cardiac Catheterization and Interventional Radiology), and Endoscopy Suites. Significant process has been made especially in the area of the Time Out. A Time Out is the step by which all work in the particular surgical area halts and everyone in the suite actively participates in ensuring that for the current surgery we have: 1. Correct patient. 2. Correct side and site. 3. Correct procedure to be done. 4. Correct patient position. 5. Correct implants and equipment. All of the Peri-Op services procedural areas brought members of their teams to participate in brainstorming and development sessions in the area of the Time Out to ensure that it was robust and all encompassing. As well, some of these components and other important details should actually be completed prior to the patient’s arrival in the surgical suite. While the Time Out is an effective last act before a surgery proceeds, many other details should and must be completed long before that. This ensures the safety of the...
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...Joint Commission Action Plan Accreditation Audit – AFT2 Task 1 Nightingale Community Hospital is a 180 bed hospital that prides itself in creating the most cost effective place to heal in the comfort of the most compassionate staff of excellence. Nightingale Community Hospital is thirteen months away from a visit from Joint Commission. The four identifying factors that we need to focus on are four areas: Information Management, Medication Management, Communication, and Infection Control to avoid falling out of compliance. I have chosen to provide an executive summary outlining the current compliance status of Nightingale in Information management. The world has been continuously transformed through various technological advances in various fields. One of those technological advances has been a great adaptation in healthcare, which is the use of EHRs (Electronic Health Records). Accurate and complete patient information is accessible to providers to improve their ability to make treatment decisions in a timely manner. All the administrative and all the clinical data are accessible in the EHR (Dimick, 2012). EHRs are more concise and accurate than paper charts because it allows for quick retrieval of various test results, allergies, problems, illnesses, infections, and procedures that the patient may have had in the present or past. Charts rarely go missing and the EHRs have been very cost effective. Nightingale has...
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...Accreditation Audit AFT2 Task 1 Executive Summary Current Compliance Status A. Compliance Status – Executive Summary Nightingale Community Hospital’s is a healthcare facility with a vision to” be the hospital of choice for patients, employees, physicians, volunteers, and the community.” We also state our mission is to create a healing environment, with a passionate commitment to healthcare excellence. Creating this vision and staying true to the stated mission requires that we adhere to the requirements set forth by the Joint Commission. In preparing for the Joint Commission visit there are focus priority areas that will need to be addressed if Nightingale is going to be compliant. The specific focus area addressed in this summary is medication management. There are three standards that come under the medication management area. The standards are listed in the table below along with their descriptions and summary of whether Nightingale Hospital has the documentation/data to be Joint Commission compliant for the given standard. Standard | Description | Joint Commission Compliance | MM.01.01.01 | The hospital plans its medication management processes. | MetNightingale PoliciesPatient Care Polices: 1. Medication Management, Patient Specific Information 2. Medication Administration | NPSG.03.04.01 | Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field. | MetNightingale Hospital...
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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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...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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...Accreditation Audit (AFT2) Task 2 Executive Summary: Root Cause Analysis Accreditation Audit (AFT2) Task 2 Executive Summary: Root Cause Analysis A. Aspects of Root Cause Analysis 1. Description of Sentinel Event Nightingale Community Hospital is conducting a root cause analysis of a pediatric abduction which occurred during a post-operative discharge process. “A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. Such events are called "sentinel" because they signal the need for immediate investigation and response.” (The Joint Commission, n.d.) In this event, a three year old child was admitted to Nightingale Community Hospital for a bilateral myringotomy. The mother of the child stepped out during the surgery in order to run an errand involving her other child. The mother was told the surgery would take about 45 minutes. The mother relayed that she should be back after the surgery to pick up her child. The mother did not respond after the recovery, even though the recovery nurse called out to the waiting area and paged for the mother. The patient was then transferred to the discharge nurse. The child was agitated waiting for her mother to return. Coincidentally, the father was at the desk and the nurse invited him to see his child. The nurse was relieved as the child changed her affect to one of excitement and called him daddy...
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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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...Accreditation Audit Task 1 AFT2 May 2015 Accreditation Audit Task 1 A.Nightingale Community Hospital is attempting to be in complete compliance with Joint Commission’s “communications” standards. Prior to the Joint Commission survey, Nightingale Community Hospital wanted to focus on items UP.01.01.01 through UP.01.03.01 of the Joint Commission handbook. According to the handbook, these items focus on the universal protocols for preventing wrong site, wrong procedure, wrong person surgery (2015). In response to these universal protocols, the hospital implemented a pre-procedure hand-off tool, which is completed and signed off by both the nurse handing off the patient as well as the nurse accepting the patient. The hospital also began implementing a “time out” form to be completed by the surgeon, all assisting surgical staff and the patient, if possible, just prior to surgery. Both of these forms follow Joint Commission’s recommendations for best practice. According to the Joint Commission Handbook, National Patient Safety Goals (NPSGs) were established by the Joint Commission to help accredited organizations address specific areas of concern in regard to patient safety (2015). Nightingale Community Hospital obtained NPSGs data regarding their compliance with communications standards, with hopes of improving their effectiveness of communication. Data was collected over the span of one year. Hospital-wide compliance of reporting critical results within 60 minutes and evidenced...
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...Melissa L. Nelcha AFT2- Task 1 Western Governors University October 25,2013 The Joint Commission has identified four distinct areas of concern within our accreditation audit. They are Communication, Information Management, Infection Control and Medication Management. While each of these is important, and vital in running Nightingale, the focus of this Summary will be on Medication Management. The reasons are as follows: * Errors can lead to increased hospital stays, possible lawsuits, and increased mortality rates, all of which affects our reputation within the community and elsewhere. * Due to the severity of the possible outcomes from medication errors, our company could end up having to pay out large sums of money to deal with repercussions of these errors in legal fees, etc. * Increasing numbers of Adverse Events can lead to a moratorium set on our facility, wherein we would not be allowed to accept any new patients, thereby losing untold amounts of money. A step this drastic can take years to fully recover from. * Having to legally inform the public of each and every adverse event coming from a Medication error could also cost us untold amounts of revenue. The Joint Commission Standard focused on in this summary will be Medication Management. There are three areas covered within the Medication Management Criteria. * Planning Medication Management processes * Labeling of Medications and devices used to administer them * Reducing patient...
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...AFT2 – Task 1 2/4/2014 Nightingale Community Hospital (NCH) is a 180-bed hospital, acute care, not-for-profit hospital that prides itself in quality healthcare. In thirteen months, NCH will face their next Joint Commission audit, and based on current findings and statistics they will need to make some adjustments to be compliant. While Joint Commission will address all the Priority Focus Areas: Infection Control, Communication, Medication Management, and Information Management, this summary will concentrate on areas in the Communication area that are lacking. A. Compliance Status UP.01.01.01: Conduct a preprocedure verification process – This Element of Performance is in place to ensure that a hospital is always performing procedures on the right patient. 1. Implement a preprocedure process to verify the correct procedure, for the correct patient, at the correct site. Nightingale Community Hospital currently has a written policy to conduct a preprocedure verification and a Preprocedure Hand-Off form to ensure information is communicated; however, there are areas lacking in the hand-off form. Although the current hand-off form has an area to verify the patient identification/armband and if the site has been marked, there is no area to verify the patient procedure and the procedure site thus leaving the hospital not in compliance with the standard. 2. Identify the items that must be available for the procedure and use a standardized list to verify their availability...
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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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