...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 checks into the...
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...Review Accreditation Audit Case Introduction The accreditation process is designed to assist healthcare establishment to identify and enhance the patient’s safety and the quality of service delivery. This paper presents a review of the readiness Nightingale Community Hospital for accreditation audit. The paper comprises of a periodic performance review of the establishment. The review has focus of several priority areas. These areas include; assessment and care; quality improvement; patient safety, and staffing effectiveness. Trend within the hospital indicates the Nightingale has made significant progress towards fulfilling the standards of the Joint Review Commission. However, the trends in staffing effectiveness are limiting the organization’s compliance. Periodic Performance Review (PPR) The PPR is based on data collected in the Joint Commission Survey. The survey utilized the priority focus methodology to evaluate the compliance of Nightingale Community Hospital. The priority focus process is a methodology that makes use of data to establish priority areas for reviewing compliance. This process has utilized of both external and internal data to evaluate the compliance of Nightingale Community Hospital. This methodology identified several priority areas. These include; assessment and care services; quality improvement activities, and patient safety. This paper evaluates Nightingale’s compliance in these three priority areas. Compliance Status The PPR process has...
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...Health and Safety in the health and social workplace Name: OLUWOLE. F. OMITOYIN Introduction: This essay intends to demonstrate a clear understanding of health and safety legislation and its implementation in health and social care settings. A review of systems, policies and procedures for communicating information in relation to legislations and individual responsibilities in term of managing health and safety will be considered. While safety priorities and how they are being implemented will be looked into. The use of information from care plan; the importance of risk assessment, the impact of policies on health care practices and how dilemma situation are managed and in addition consequences of non-compliance with law and regulation will be discussed. Lastly, the essay will critically look at how health and safety arrangement are monitored and review and also analyse the effectiveness of positive health and safety culture in health care organisation. In conclusion, my own contribution to health and safety needs will be discussed and recommendation made. Task 1: 1.1 According to oxford English dictionary (2014) “Policy is defined as a course or principle of action adopted or proposed by an organisation to direct and limit its action in pursuit of a long term goals,” examples smoking policy, manual handling policy. While a procedure on the other hand is an established or official ways of doing things or a series of actions conducted in a certain order or manner...
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...A. Compliance Status The following executive summary focuses not only on the identified gaps in the current process, but also the corrective action plan to support compliance in the noted areas of the Communications Standards as provided by The Joint Commission, (National Patient Safety Goals, 2013). The high risk associated with surgical procedures performed on the wrong site has driven a risk mitigating approach to the processes involved for these procedures. The goal is to prevent harm to patients having a surgical procedure. The following summary is the current compliance status if the Priority Focus Area of Communication for Nightingale Community Hospital. After review of the specific areas identified in the Priority Focus Area, the following have been identified as requiring further attention: time-outs are routinely performed prior to every procedure (UP 01.03.01) and procedure site is marked (UP 01.02.01). Based on the evaluation of the Nightingale Community Hospital National Patient Safety Goals for Communications the current compliance rate related to the Universal Protocol Time-Out processes performed hospital wide indicate a 95% to 100% compliance rate for the year. The graph provided in the Nightingale Community Hospital National Patient Safety Goals Communication assessment provides limited information as these are hospital wide percentages. No unit specific evaluations of performance have been provided in the report. Upon review of the Site Identification and...
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...usual age of disease onset and if the sex-specific threshold model fits the disorder. What education could you present to high-risk patients to reduce the risk of disease onset if a multifactorial component exists? Question 2= Genetic screening has become widely available to the public including prenatal screening of the fetus in utero to screening adults for genetic disorders, such as Parkinson's disease and breast cancer. Share your thoughts on the legal, ethical, and social implications that may be related to genetic screening. How would you educate your patient that is considering having genetic screening? Week 2: Question 1= Choose an FDA-approved prescription medication and discuss the pharmacokinetics and pharmacodynamics of the medication, including any differences that would be expected based on the patient's age, a condition of pregnancy, or lactation. Address any adverse effects the medication may have based on age, pregnancy, or lactation. Question 2= Active acquired immunity can be achieved through the use of childhood immunizations. Many parents voice concerns regarding the safety of vaccinations. What is your opinion on the current use of vaccinations? How would you educate parents regarding the safety and effectiveness of vaccinations? Defend your answers with evidence-based research. Week 3: Question 1= Share a case study of an electrolyte imbalance from your practice or from the...
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...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 to enable the hospital be in full compliance with Joint Commission standard. There are some discrepancies that has to be looked into and resolve to enable NCH maintain the standard compliance with the Joint Commission. Instead of looking into problems found in each unit, there are trends affecting the hospital's patient care standard of complying...
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...into effect. According to Health Services Research Information Central, the definition of health informatics is, “the interdisciplinary study of the design, development, adoption, and application of IT-based innovations in healthcare services delivery, management, and planning.” Healthcare informatics is used to gather, analyze, and interpret data and information about patients and treatments. This information, along with business and management information, is used to interpret how things are and to develop a better, more efficient and more cost effective method of operation. The big question is, how does healthcare informatics and technology effect or impact the development and implementation of healthcare law? One of the most effective technologies that has been widely adopted already is electronic health records. EHR are systems that track and record patient information. It also makes them more accessible and easier to share and communicate between doctors, patients and insurance companies. Electronic health records help control costs effectiveness of an organization by communicating information in a timely manner and helps secure payments more effectively than paper billing. With all of the changes and easier access to a patient’s confidential records, obviously healthcare laws and regulations would change in order to protect patient safety. With the positive effects of EHR, it also...
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...Hand Hygiene Compliance in Health Providers Grand Canyon University: NRS 433 11/17/13 The purpose of this article “The impact of workload on hygiene compliance in nursing” was to shade some light and reveal some of the findings the researchers come across during the previous questions posed. They wanted to know the reasons why nurses are noncompliant when it comes to hand hygiene. The study lasted twelve-month during which time the staff were observed in a hospital setting in six different settings. The researchers were set to find out the leading causes of nursing staff noncompliance with hand washing while hospital acquired infections were on the rise. Researchers surveyed multiple units in a large hospital and concluded the following the result as recorded. All staff members were interviewed and monitored by the same interviewer for consistency and accuracy. The interviewer then placed each subject in a category as compliant or noncompliant and the subsequent reason for such a placement was noted. Next the observer proceed to observe the participants in their normal environment while they were performing their routine duties, subjects were chosen at random without announcement to be studied. The evaluation consisted of 181 participants, it was divided into seven groups. The categories varied from nurses who did not performed proper hand washing because of the time restraint all the way to those who spoke up when they see another coworker...
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...A. Compliance Status The Joint Commission, JC, conducts reviews to provide accreditation to facilities based on compliance with federal and state rules and regulations as well as the accrediting body’s standards. The Accreditations Audit Case Study on Nightingale Community Hospital, NCH, for this task is based on documentation reviewed and pre-survey data collection thirteen months prior to the next Joint Commission review. This discussion provides an executive summary and current compliance status for one priority focus area for NCH as well as Plan of Correction and Justification for the needed actions. JC standards outline priority focus areas in the areas of Assessment and Care/Services, Quality Improvement Expertise/Activities, Communication, Infection Control and Patient Safety. For the purpose of this discussion, the Primary Focus Area of Communication will be discussed as it pertains to NCH. The JC Standards identify communication as the process for information exchange between organizations, departments, or individuals. This includes provider and staff communication, staff-to-patient communication, patient and family education, collaboration of services, multidisciplinary team work, and information dissemination. In preparation for the JC accreditation review, NCH reviewed the JC Communication standards pulled from UP.01.01.01; UP.01.02.01; and UP.01.03.01 and compared against the NCH policy and operations as well as data collected through the General Safety...
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...have close the gap to provide a better, and safety quality patient care. Rationale What is risk management any way not everyone has the same meaning. It can be define as such Risk management is a process for identifying, assessing, and prioritizing risks of different kinds. Once the risks are identified, the risk manager will create a plan to minimize or eliminate the impact of negative events. A variety of strategies is available, depending on the type of risk and the type of business. Outline Risk Management and Patient Safety: The Synergy and the Tension Integrating Risk Management, Quality Management, and Patient Safety into the Organization Benchmarking in Risk Management Risk Management Strategic Planning for a Changing Health Care Delivery System Using Never Events to Reduce Risk and Advance Patient Safety Governance and Board Responsibility to Assure Safety in Health Care Organizations 1. Introduction What is the goal or the idea behind risk management one of their focus is to reduce the financial risk other areas that may seem not important is the regulation. One of the principal issues facing health care risk management is governmental regulation. Over the last few decades, there has been a growing public demand for accountability in health care delivery. The consequent tightening of governmental regulation has led to a greater allocation of an organization's resources to regulatory compliance. Some states, including New York, enacted...
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...important is the regulation. One of the principal issues facing health care risk management is governmental regulation. Over the last few decades, there has been a growing public demand for accountability in health care delivery. The consequent tightening of governmental regulation has led to a greater allocation of an organization's resources to regulatory compliance. Some states, including New York, enacted stringent incident reporting requirements for hospitals, requiring additional staff to investigate and prepare such reports. Additionally, competition among hospitals has also fostered a greater concern over the community's perception of quality of care. Many hospitals have had to compete harder for patients as inpatient lengths of stay decrease and more procedures are performed on an outpatient basis. Risk management in the health care In the past risk management and quality improvement job was separate in the health care organization. Even though, the job function may have been different the goal was the same. Managing risks is the quality of services provided & the safety of patients, their careers & visitors. To manage risks to staff & subsequent risks to service quality. To manage risk of failing to meet national & local priority targets to manage risks to the efficiency of services. To manage risks to the reputation of the hospital Risk management aims to identify the major sources of risks to hospital, staff & visitors. Develop regular...
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...Epidemiology – A Case Study Landon Hazel Dr. Cynthia Davis HSA 535 October 22, 2014 Introduction The Good Health hospital has a minor 6 person nosocomial infection of E. coli. The role of the social science researcher is to investigate dissimilar patterns and causes of the E. coli and its bearing on the patients. The science researcher also understands that litigation issues are also in question because the hospitals are anticipated to safely inhibit the spread of any diseases from patient to patient. In many cases Good Hospital could be held liable for negligence. By contacting the DOH and CDC for data related to nosocomial diseases, the researcher can gain valuable information about different ways to contain the spread. After the data is gathered, the researcher can effectively prepare an evaluation report. This report will include information in detail about nosocomial infections as well as considerations for Good Hospital to handle the problem effectively. Analyze Good Health Hospital’s records and itemize recent nosocomial infections that occurred within the past year. In your report, categorize the different parameters (i.e., person, time, place, ethnicity, and gender) used in the compilation of data into the information summative. In an evaluation of the information that we do recognize about Good Health Hospital is that the outbreak of E. coli was triggered in fact by spoil food from the cafeteria. The E. coli outbreak has six known cases. Four of the confirm...
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...------------------------------------------------- Applications of Epidemiology – A Case Study Shaneil White July 19, 2015 hSA505 Dr. Chad Moretz July 19, 2015 hSA505 Dr. Chad Moretz Analyze Good Health Hospital’s records and itemize recent nosocomial infections that occurred within the past year. In your report, categorize the different parameters (i.e., person, time, place, ethnicity, and gender) used in the compilation of data into the nformation summative. Currently at the Good Health Hospital, there’s a nosocomial outbreak of E. coli on Ward 10 on the second floor. Four cases have been identified so far linked to spoil food from the cafeteria, with two more cases pending. After meeting with chief administrator Joe Wellborn, one patient could possibly been symptomatic with the bacteria prior to admission. Parameters discussion below: * Person: 4 identified cases. (1. Male, age 23), (2. Female, age 21), (Male, age 15), and (Female, age 42). * Place: Good Health Hospital, Ward 10, second floor; Good Health Hospital cafeteria. Also research has indicated that other area hospitals around Tampa Bay has been contaminated with E. coli as well. * Time: Within the past week. Propose at least six (6) questions for the health care administrator at Good Health Hospital, regarding potential litigation issues with infections from the nosocomial diseases. Rationalize, in your report, the logic behind your six (6) questions. Traditionally, nosocomial infections have generally...
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...in more recent times there have been stories of unethical research that has taken place in society and rather than work toward managing a business for the better, we find that research was and has harmed companies and consumers involved. In 2007 and 2008 GlaxoSmithKilne was fined over $80,000 for the killing of 14 babies during an illegal lab research vaccine trial. Glaxo plead guilty and paid a criminal fine for misreporting data and failing to report adverse safety data from post marketing studies (Belkin), 2013). In July 2012, GlaxoSmithKline, also known as GSK, agreed to plead guilty and pay $3 billion to resolve the criminal and civil liabilities stemming from the unlawful promotion of prescription drugs. They failed to report safety data and falsified reporting practices. This is the largest health care settlement in the history of the United States. James M. Cole, Deputy Attorney General, is quotes as saying, “At every level, we are determined to stop practices that jeopardize patients’ health, harm taxpayers, and violate the public trust – and this historic action is a clear warning to any company that chooses to break the law” (US Fed News Service, pg. 1, paragraph 4, 2012). With the charges come strict requirements to increase accountability and prevent future misleading research and fraud. During the investigation it was found that three drugs were used under...
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...facility to 90% within 6 months. TEAM MEMBERS AND ROLES Team Member Role/Importance Medical Director Acts as the sponsor of the project and provides accountability for the team members. Serves as the executive link providing resources and helping the team overcome barriers. He is also the team's clinical leader because he has the authority to implement the change and understands the implications of the proposed changes to the system. Pharmacist The pharmacist has technical expertise on drug therapy and can improve safety by identifying duplications in medication regime and possible medication interactions. Also serves to help review medications if a physician is not familiar with them. Registered Nurse Serves as a project driver by...
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