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General Instructions: EXAM TOTAL OF 12 PAGES ACCREDITATION AND AUDIT TASK 1 ? 3 PAGES TASK 1 ? 3 PAGES TASK 1 ? 3 PAGES TASK 1 ? 3 PAGES Exam task 1 – 3 PAGES accreditation and audit SUBDOMAIN 705.2 – HEALTHCARE ECONOMICS & FINANCE SUBDOMAIN 705.4 – HEALTHCARE VALUES, POLICY, & LAW Competency 705.2.4: Regulatory Audits – The graduate ensures a healthcare organization is in compliance with mandatory regulatory audit guidelines pertaining to the organization. Competency 705.4.3: Compliance – The graduate identifies and helps a healthcare organization comply with applicable healthcare statutes and regulations. ________________________________________ Introduction: In this task, you are preparing for an accreditation audit. There are many variables that must be considered to ensure compliance with Joint Commission standards. In order for the audit to be successful, you must be aware of the accrediting agency?s guidelines. Task: A. Create an executive summary for senior leadership outlining the current compliance status of the organization based on the attached Accreditation Audit Case Study – Task 1 Artifacts for one priority focus area of the Joint Commission standards (e.g., infection control, communication, medical management, information management). 1. Develop a corrective action plan that would ensure compliance with the Joint Commission standards for the identified area. 2. Justify why the review area that you selected is important to the hospital. B. When you use sources, include all in-text citations and references in APA format. Note: When bulleted points are present in the task prompt, the level of detail or support called for in the rubric refers to those bulleted points. Note: For definitions of terms commonly used in the rubric, see the Rubric Terms web link included in the Evaluation Procedures section. Note: When using sources to support ideas and elements in a paper or project, the submission MUST include APA formatted in-text citations with a corresponding reference list for any direct quotes or paraphrasing. It is not necessary to list sources that were consulted if they have not been quoted or paraphrased in the text of the paper or project. Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from sources, even if cited correctly. For tips on using APA style, please refer to the APA Handout web link included in the APA Guidelines section. File Attachments: 1. Accreditation Audit Case Study – General Artifactslink opens in new window 2. Accreditation Audit Case Study – Task 1 Artifactslink opens in new window Evaluation Method Task 2 exam —- 3 pages accreditation and audit SUBDOMAIN 705.3 – HEALTHCARE OPERATIONS MANAGEMENT Competencies: 705.3.2: Resource Assessment – The graduate identifies and assesses external and internal resources available to a healthcare organization. 705.3.5: Quality Improvement – The graduate designs quality improvement programs to enhance the level of patient care in a healthcare organization. 705.3.8: Risk Management – The graduate develops risk management programs that result in improved quality patient care. 705.3.9: Effective Interactions – The graduate can effectively interact with physicians, nurses, and other healthcare providers. ________________________________________ Note: For this task you will use an attachment in Shockwave Flash Format. This format can be opened with Adobe Flash. You may also download the free GOM Media Player online to open this attachment. Note: The attachments for this task are for informational purposes only. They do not need to be submitted as work to be evaluated for this task. Introduction: The Joint Commission requires a root cause analysis for all sentinel events. These analyses can be of enormous value. They capture both the big-picture perspective and the details. They facilitate system evaluation, analysis of need for corrective action, and tracking and trending. Managers will be able to determine how often a particular error occurs or how often a particular floor or unit of the hospital is involved. This information may provide clues to the problem. A root cause analysis is very useful and important especially in near-miss scenarios. The technique is applicable not only to laboratory medicine but also to other healthcare-associated disciplines. Task: A. Provide a summary of the following aspects of a root cause analysis related to the sentinel event found in the attached Accreditation Audit Case Study ? Task 2 Specific artifacts by doing the following: 1. Describe the sentinel event. 2. Explain the roles (i.e. responsibilities, etc.) of the personnel present during the sentinel event. 3. Discuss the barriers that may impede effective interaction among the personnel present during the sentinel event. a. Propose ways to improve interactions among the personnel present. 4. Discuss a quality improvement tool to be used to conduct the root cause analysis. B. Outline a corrective action plan to ensure that the sentinel event does not recur by doing the following: 1. Recommend a risk management program or process change to ensure that the sentinel event does not recur. a. Discuss resources available to support these changes. C. When you use sources, include all in-text citations and references in APA format. Note: When bulleted points are present in the task prompt, the level of detail or support called for in the rubric refers to those bulleted points. Note: For definitions of terms commonly used in the rubric, see the Rubric Terms web link included in the Evaluation Procedures section. Note: When using sources to support ideas and elements in a paper or project, the submission MUST include APA formatted in-text citations with a corresponding reference list for any direct quotes or paraphrasing. It is not necessary to list sources that were consulted if they have not been quoted or paraphrased in the text of the paper or project. Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from sources, even if cited correctly. For tips on using APA style, please refer to the APA Handout web link included in the APA Guidelines section. File Attachments: 1. Accreditation Audit Case Study – General Artifactslink opens in new window Web Links: 1. Accreditation Audit Case Study – Task 2 Artifactslink opens in new window Evaluation Method Task 3 exam —- 3 pages ACCREDITAION AND AUDIT UBDOMAIN 705.3 – HEALTHCARE OPERATIONS MANAGEMENT Competency 705.3.4: Patient Care Improvement – The graduate interprets quality assessments and prioritizes patient care improvement needs. ________________________________________ Introduction: In this task, you will use a tracer methodology to track a patient?s care in order to evaluate the healthcare organization?s systems of providing care and services for a readiness audit. This methodology also makes it possible to assess the healthcare organization?s compliance with Joint Commission standards. This is part of the organization?s compliance with delivering safe, quality healthcare. You will examine data for a patient that is found in the attached ?Accreditation Audit Case Study ? Task 3 Artifacts? and find any trends, patterns, and problems. Once these have been identified, you can remediate the concerns. Task: A. Review the tracer patient information from the attached Accreditation Audit Case Study – Task 3 Artifacts and do the following: 1. Discuss an outstanding patient care issue for the organization made evident by the tracer patient. 2. Develop a corrective action plan to address the patient care improvement needs for the organization using a keyword search in the Joint Commission electronic manual. B. When you use sources, include all in-text citations and references in APA format. Note: When bulleted points are present in the task prompt, the level of detail or support called for in the rubric refers to those bulleted points. Note: For definitions of terms commonly used in the rubric, see the Rubric Terms web link included in the Evaluation Procedures section. Note: When using sources to support ideas and elements in a paper or project, the submission MUST include APA formatted in-text citations with a corresponding reference list for any direct quotes or paraphrasing. It is not necessary to list sources that were consulted if they have not been quoted or paraphrased in the text of the paper or project. Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from sources, even if cited correctly. For tips on using APA style, please refer to the APA Handout web link included in the APA Guidelines section. File Attachments: 1. Accreditation Audit Case Study – General Artifactslink opens in new window Web Links: 1. Accreditation Audit Case Study – Task 3 Artifactslink opens in new window Evaluation Method Task 4 exam – 3 pages ACCREDITATION AND AUDIT SUBDOMAIN 705.2 – HEALTHCARE ECONOMICS & FINANCE SUBDOMAIN 705.3 – HEALTHCARE OPERATIONS MANAGEMENT SUBDOMAIN 705.4 – HEALTHCARE VALUES, POLICY, & LAW Competency 705.2.4: Regulatory Audit – The graduate ensures a healthcare organization is in compliance with mandatory regulatory audit guidelines pertaining to the organization. Competency 705.3.6: Organization Plans – The graduate prepares organizational plans such as disaster plans, contingency plans, or staffing plans. Competency 705.4.3: Compliance – The graduate identifies and helps a healthcare organization comply with applicable healthcare statutes and regulations. ________________________________________ Introduction: The accreditation process seeks to help organizations identify and resolve problems and to inspire them to improve the safety and quality of care and services provided. The process focuses on systems critical to the safety and the quality of care, treatment, and services. For this task, you will assume the role of director of accreditation. You will review and analyze the materials (e.g., records, previous audit, trends, e-mails) provided in the case study to prepare for the audit. You will need to look across all departments and examine trends and patient care issues to determine readiness. Task: A. Facilitate an organization?s continuous accreditation compliance process as you determine the readiness for the accreditation audit of the healthcare facility in the attached Accreditation Audit Case Study – Task 4 Artifacts by doing the following: 1. Discuss the current compliance status of the healthcare facility. 2. Discuss any trends evident in the Accreditation Audit Case Study – Task 4 Artifacts that may cause the organization to not be compliant with the Joint Commission standards for patient care. 3. Review the performance improvement standard regarding staffing in the healthcare facility?s patient care unit by doing the following: a. Analyze the data to determine the staffing patterns of the patient care unit. b. Develop a staffing plan to minimize the number of falls in the patient care unit. Note: If you have problems opening the Audit Case Study – Task 4 Artifacts file, download the file first, and then open it B. When you use sources, include all in-text citations and references in APA format. Note: When bulleted points are present in the task prompt, the level of detail or support called for in the rubric refers to those bulleted points. Note: For definitions of terms commonly used in the rubric, see the Rubric Terms web link included in the Evaluation Procedures section. Note: When using sources to support ideas and elements in a paper or project, the submission MUST include APA formatted in-text citations with a corresponding reference list for any direct quotes or paraphrasing. It is not necessary to list sources that were consulted if they have not been quoted or paraphrased in the text of the paper or project. Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from sources, even if cited correctly. For tips on using APA style, please refer to the APA Handout web link included in the APA Guidelines section.
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