Premium Essay

Wgu Accreditation Audit Aft2 Task 4

In: Business and Management

Submitted By audlady
Words 2777
Pages 12
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 standards are met. The PPR identified the following trends of non-compliance: verbal orders authenticated in a timely manner, prohibited abbreviations, lack of proper documentation, and clutter in hallways. The PPR also identified a particular area of NCH, 3E, which had an increased amount of issues as compared to other departments.

Verbal Orders Authenticated in Timely Manner…...

Similar Documents

Premium Essay

Accreditation Audit Task 1

...area of Title VII. Constructive discharge is an employment situation whereby the employee feels that due to changes their employer has made with regard to any Title VII covered entity; they have no option but to resign. This act is relevant to the claim in that the claim stated that the employee felt he had no alternative but to resign. The employee believed that with the company’s new policy reflecting work/shift changes he would not be able to observe the Holy days required by his religion. In response to our company’s growth, the schedules and hours of production employees were evaluated to provide the best business outcomes. It was determined that production shifts be increased to 12 hours a day with a varying schedule of 4 days on and 4 days off to include all days of the week. Each production employee would be required to work these shifts however this new work schedule would not impact office staff; they would continue to work Monday through Friday 8am until 5 pm. The language of this compliant reflects that the employee, who was not office staff, felt that the work schedule changes would require him to work on what he considered religious holy days which would fall on the days of the week he would be required to work. The employee’s complaint is clear that he felt he had not alternative but to resign. This he believed was a violation of the Title VII act with specific regard to constructive discharge. When a constructive discharge complaint is brought......

Words: 1763 - Pages: 8

Premium Essay

Wgu Aft2 Accreditation Audit Task 1

...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......

Words: 1070 - Pages: 5

Premium Essay

Aft2 - Joint Commission Audit Task 1

...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......

Words: 581 - Pages: 3

Premium Essay

Wgu Aft2 Accreditation Audit Task 2

...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......

Words: 2935 - Pages: 12

Premium Essay

Accreditation Audit Task 4

...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......

Words: 3108 - Pages: 13

Premium Essay

Accreditation Audit Task 1

...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......

Words: 1046 - Pages: 5

Premium Essay

Accreditation Audit Task 3

...admission assessment but no record was found. It is crucial to gain knowledge of the patient’s history and perform a physical within 24 hours of admission to provide the patient with safe and quality medical care. Another deficiency noted in the survey was the initial nursing plan of care was documented but was not updated since surgery. During treatment, it is important to collect and record accurate and most up-to-date information from the patient to ensure the best possible care. Other deficiencies made evident by the tracer patient were a nurse’s inability to explain the range order policy when administering medication to patients. Pain medications are to be check for effect within 1 hour after ingestion but documentation showed the last 4 times that checking for effect exceeded 1 hour after administering pain medication to the patient. It is recommended to start with the lowest dose ordered and work up if necessary. Finally, the hand-off process noted in the survey as disjointed as well as the use of hand-off form was inconsistent. According to the Joint Commission, passing critical and necessary information at the time of transfer has been a pain point for many healthcare organizations. It is estimated that 80% of serious medical errors involve miscommunication when patients are transferred between caregivers. (Kulczycki, 2012) 2. Corrective Action Plan: Nightingale Community Hospital is deficient in following certain protocols and keeping documentations of......

Words: 440 - Pages: 2

Premium Essay

Wgu Aft2 Raft2 (Accreditation Audit) Mba Graduate Programe - Complete Course All 4 Tasks

...WGU AFT2 RAFT2 (Accreditation Audit) MBA Graduate Programe - Complete Course All 4 Tasks 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......

Words: 982 - Pages: 4

Premium Essay

Accreditation Audit Task 1

...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......

Words: 2426 - Pages: 10

Free Essay

Wgu Accreditation Audit Aft2 Task 1

...Executive Summary - Preparation for Accreditation Audit AFT2 Accreditation Audit September 26th, 2014 Executive Summary - Preparation for Accreditation Audit Nightingale Community Hospital (NCH) offers comprehensive care for a wide range of conditions and is a leader amongst its peers in providing compassionate and quality care. To meet their main mission of putting patients care first, NCH consistently endeavors to meet and exceed standards set forth concerning medication management by the Joint Commission. This is exemplified in NHC’s clear and concise policies concerning medication administration, medication safety, and anticoagulation therapy. These policies and programs provide the framework upon which NHC meets Joint Commission Accreditation requirements. Current Compliance Status During the next audit, in 13 months, the Joint Commission has three priority focus areas concerning medication management which includes: 1. Planning of Medication Management Process 2. Labeling of all medications in all areas, all forms 3. Reduce Patient harm associated with anticoagulant therapy Currently NCH has appropriate measures, policies, and programs in place concerning medication management to meet accreditation requirements. Policies and programs are thorough and include protocols for collecting information that would spotlight an area of opportunity for improvement. Through the use of data collection it has been determined...

Words: 983 - Pages: 4

Premium Essay

Wgu Accreditation Audit Aft2 Task 2

...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......

Words: 2157 - Pages: 9

Premium Essay

Wgu Accreditation Audit Aft2 Task 3

...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...

Words: 992 - Pages: 4

Premium Essay

Aft Task 4, Wgu

...AFT Task 4: Periodic Performance 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......

Words: 2525 - Pages: 11

Premium Essay

Wgu Aft2 Task 1

...------------------------------------------------- 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......

Words: 1609 - Pages: 7

Premium Essay

Accreditation Task 4 means the hospital needs to maintain compliance with the Joint Commission standards and provide consistent and quality care to its recipients. Compliance is a difficult task to achieve. It requires great effort on the part on the administrators and work force and requires the collaboration of interdisciplinary teams to bring about the desired effect. In order to monitor compliance, the hospital utilizes a periodic performance review (PPR) tool to assess its performance by continuous monitoring and performance improvement activities. The PPR provides the chassis for continuous standards compliance and focuses on the essential systems and practices that affect patient care and safety. The hospital self-evaluates its adherence with all Joint Commission Accreditation Participation Requirements, National Patient Safety Goals, related Elements of Performance (EPs), and develops a Plan of Action for all areas of performance identified as being non-compliant. The hospital also develops Measures of Success (MOS) for determining whether the organization is successful in resolving identified problems. Nightingale Community Hospital provides various medical, surgical, ambulatory care, laboratory, pediatric and emergency services and is thereby accountable for maintaining compliance as per accreditation policies. Areas of Compliance Joint......

Words: 1534 - Pages: 7