ACCREDITATION AUDIT – TASK #4

COMPETENCIES

705.2.4 Regulatory Audit

The graduate ensures a healthcare organization is in compliance with mandatory regulatory audit guidelines pertaining to the organization.

705.3.6 Organization Plans

The graduate prepares organizational plans such as disaster plans, contingency plans, or staffing plans.

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.

REQUIREMENTS

Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. An originality report is provided when you submit your task that can be used as a guide.

You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.

 

1.  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:
2.  Discuss the current compliance status of the healthcare facility.
3.  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.
4.  Review the performance improvement standard regarding staffing in the healthcare facility’s patient care unit by doing the following:
5.  Analyze the data to determine the staffing patterns of the patient care unit.
6.  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

1.  When you use sources, include all in-text citations and references in APA format.

 

RUBRIC

ARTICULATION OF RESPONSE (CLARITY, ORGANIZATION, MECHANICS): 

COMPETENT

The candidate provides adequate articulation of response.

 

HIGHLY COMPETENT

The candidate provides substantial articulation of response.

 

A1:COMPLIANCE STATUS

COMPETENT

The candidate provides a logical discussion, with adequate detail, of the current compliance status of the healthcare facility.

 

HIGHLY COMPETENT

The candidate provides a logical discussion, with substantial detail, of the current compliance status of the healthcare facility.

 

A2:NONCOMPLIANT TRENDS

COMPETENT

The candidate provides a logical discussion, with adequate detail, of any trends evident in the case study that may cause the organization to not be compliant with the Joint Commission standards for patient care.

 

 

 

 

HIGHLY COMPETENT

The candidate provides a logical discussion, with substantial detail, of any trends evident in the case study that may cause the organization to not be compliant with the Joint Commission standards for patient care.

 

A3A:STAFFING PATTERNS

COMPETENT

The candidate provides a plausible analysis, with adequate support, of data to determine the staffing patterns of the patient care unit.

 

HIGHLY COMPETENT

The candidate provides a plausible analysis, with substantial support, of data to determine the staffing patterns of the patient care unit.

 

A3B:STAFFING PLAN

COMPETENT

The candidate provides a staffing plan, with adequate detail, to minimize the number of falls in the patient care unit.

 

HIGHLY COMPETENT

The candidate provides a staffing plan, with substantial detail, to minimize the number of falls in the patient care unit.

 

B:SOURCES  (not part of  main paper)

COMPETENT

When the candidate uses sources, the candidate provides appropriate in-text citations and references with minor deviations from APA style.

 

HIGHLY COMPETENT

When the candidate uses sources, the candidate provides appropriate in-text citations and references with no readily detectable deviations from APA style, OR the candidate does not use sources.

 

 

 

SUPPORTING DOCUMENTATION

SUPPORTING DOCUMENTS

Accreditation_Audit_Case_Study_-_General_Artifacts.zip

Accreditation_Audit_Case_Study_-_Task_4_Artifacts.zip

 

GENERAL ARTIFACTS

TASK 4 ARTIFACTS