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.
AFT 2 TASK 1
Presented by- Dr. R. Austin Arenz III DM,
MSM/MHR, MPA, MPH, aPHR, MBAHC, RT
Accreditation
Task 1 Getting Started
You are role playing as
the Director of
Compliance for
Nightingale Hospital.
You are writing an
executive summary to
senior management
describing the
compliance status of
Nightingale Hospital
TASK 1 TIPS
Not a TJC Finding
You are not fixing
issues found by the
TJC. Rather you are
preparing to see that
each area is ready for
the TJC. You will only
pick one section.
UP (under the NPSG)
IC (Infection Control)
MM (Medication
Management)
IM (Information
Management)
Preparing for AFT2 Task 1
Open the course in Student Portal
Click on Course Search *Click
on Videos
Task 1 Preparing the paper
Header 1 – Compliance Status
Decide which standard
(found in the Review Area
document) and
decide which one you are
interested in.
Look at the standard number in
the middle
column of the Review Document.
These numbers will correspond to
the standard in the JC Electronic
Manual.
Task 1 Preparing the paper
Header 1 – Compliance
Status (continued)
To determine what is
in compliance and
what is not, Locate
the Evidence of
Performance (EP)
[within the specific
standard]
Preparing for AFT2 Task 1
Open the course in Student Portal
Click on Course Search *Click
on Videos
TASK 1 PREPARING THE PAPER
Preparing for Task 1 continued
Task 1 Preparing the paper
Open course in Task Stream/Assessment
Click on Task 1. You will find two
files attached.
Accreditation Audit Case
Study General Artifacts
Accreditation Audit Case
Study Task 1 Artifacts
Click on the zip file
Download the Review
Area document and the
documents you will
evaluate
Click on Evaluation Method
rubric
Download
Download these documents General Artifacts information about Nightingale Hospital – Helpful
information about your hospital
Audit case study – These documents are
necessary for completion of the task
When you open the file you will see 20
documents. Not necessary to open and download
all 20. You only need to look at 1 area. Pick one
area and download each document reflective of
the area (communication, infection control,
information management, medication
management) *(Might be good to print off a hard
copy for ease of review)*
When setting up your paper include each of the
headings found in the rubric.
A Possible Format
Communication Compliance
When considering the compliance level of the organization
we must consider the 13 elements espoused by the commission
when compared to our hospitals policies. These requirements are
(TJC, 2018):
1) Implement a pre-procedure process to verify the correct
procedure, for the correct patient, at the correct site.-This
requirement is met by the Site Identification and
Verification Policy.
Task 1
Header 2 Plan for Compliance
Any area that is not in
compliance will be the basis
for your corrective action
plan. Areas required in action
plan
Action steps needed:
*Who is accountable
*When will it be completed/deadlines
*How will it be monitored/measured
Task 1 Preparing the paper
Header 3 Justification
Discuss why your chosen area is
important to Nightingale, JC and
overall patient care or health care.
Use outside resources
Tips for success
Make sure that you paraphrase
JC keep authenticity % low
Keep it simple, but detailed
follow rubric expectations
Write as if you are the Director
of Compliance providing a
report to Senior Management,
not as a student submitting a
paper for grading.
Possible Format
A
A1
Introductory Paragraph
Corrective Action Plan (CAP)
Compliance status- Compliant with
1- Which one, what needs fixing- Who will
administer Training, time frame, Metric
2- Which one, what needs fixing- Who will
administer Training, time frame, Metric
3) ********
3- Repeat as needed
4) ********
A2
5) ********
Justification- 1-2 Paragraphs typicallyArticle Summary (does not come from the
class materials) Cite work and why it is
important to nightingale.
1) Implement a pre-procedure process to verify the correct procedure, for the
correct patient, at the correct site.-This requirement is met by the Site
Identification and Verification Policy.
2) *********
6) ********
7) ********
8) ********
13) ********
RUBRIC REVIEW
RUBRIC REVIEW
CONTACT INFORMATION
Dr. Russell Austin Arenz III
[email protected]
EXT-4976
Task 1 Final Thoughts
Keep it simple, but
detailed follow
rubric expectations
Write as if you are the
Director of Compliance
providing a report to
Senior Management,
not as a student
submitting a paper for
grading.
Nightingale Community Hospital
Its how we treat you.
Our Care
Nightingale Community Hospital provides leadership in
quality health services. We also provide compassionate and
cost-effective service in the lines of treatment and
prevention.
Our vision is to be the hospital of choice for patients,
employees, physicians, volunteers, and the community.
Our mission is to create a healing environment, with a
passionate commitment to healthcare excellence.
Our patients see our passion the moment they walk in the
door. From reception to discharge, we treat you well.
The future depends
on what we do in the present.
Mahatma Gandhi
How We Treat You
Nightingale Community Hospital is a 180-bed, acute care,
not-for-profit community hospital. We provide services in
these areas:
General Medical/Surgical Services
We partner with our states Surgical Care Initiative (SCI) to
provide the best care possible. To locate a doctor thats right for
you, call 555-0988.
Critical Care & Emergency Services
Our ER service has recently won a SCOPE award for best
customer service in an ER. Visit us and see why! Call 555-0987 for
more details.
Oncology
Our oncology services are second to none. We understand how
cancer affects the whole family, so we provide comforting suites
for service, with attention to patient comfort and effective
treatment. To start your journey to wellness, call 555-6785.
Cardiology
Services include a dedicated cardiac catheterization lab, sameday diagnostic procedures and the only nationally certified
cardiac rehab program in Spring County. Call us at 555-3456 to
schedule your heart.
Neuroscience Unit
The inpatient acute care Neuroscience Unit at Nightingales cares
for patients who are being treated with surgery or medicine for
brain injury, spinal injury, stroke, trauma, multiple sclerosis, ALS,
Alzheimer’s disease, and seizures related to neurological
disorders.
Orthopedics
A total renovation of this unit last year transformed it into a
warm and healing environment for patients and their visitors.
Caregivers on this unit are specially trained to care for patients
who have had orthopedic surgeries. And they continually finetune their skills by caring only for orthopedic patients.
Imaging Services
Our imaging equipment includes MRI, PET-CT, and CT Scans that
allow us to record your health, diagnose the problem and plan
medical treatment with you.
Obstetrics
Obstetric services at Nightingales combine the talents of
hospital-based and community specialists to bring complete care
to our patients. Our broad range of programs and expertise help
women prepare for pregnancy, then guide them through both
routine or high risk pregnancies to the birth of the baby. Special
attention is given to meeting the family’s expectations of the
birthing process.
Level II Nursery
Specially trained physicians and nurses provide care 24 hours a
day in the Telemetry Care Unit, which assists patients who need
specialized cardiac care and monitoring.
We understand that you want the best possible care for your
baby. The good news is that Nightingales offers a Level II
Neonatal Intensive Care Nursery. This means that we can take
care of newborns with a wide variety of special care needs,
allowing mother and baby to stay in the same hospital.
Vascular Lab
Endoscopy and Surgery
The Noninvasive Vascular Laboratory (the “Blood flow lab”) is
one of the key components of the Nightingale Vascular Lab.
Noninvasive testing, as the name implies, allows patients to be
examined using Doppler ultrasound techniques free of the risks
and discomforts of injections and/or other invasive maneuvers.
Our highly trained staff of registered nurses and technicians are
cross-trained in all areas of Endoscopy Services.
Telemetry Care
Our Values
We expect of ourselves, and pledge to our communities, a
commitment to four core values:
Safety
We believe that excellence begins with providing a safe
environment. We put our patients first as we seek to
exceed the expectations of our customers with superior
service, outstanding clinical care and unsurpassed
responsiveness.
Community
We reach beyond our walls to engage in partnerships that
improve the education and healthcare needs of our
community. We invest in the community by continually
improving services and broadening our spectrum of care.
Teamwork
We collaborate with others for the benefit of all. We
acknowledge differences among people and recognize
strength of diversity.
Accountability
We provide cost-effective, quality services; we foster the
financial strength, stability and growth of Nightingale’s;
and we support individual initiative and innovation.
The sum of the whole is this:
walk and be healthy.
Charles Dickens
Joint Commission Survey Results
2 years ago
PC.01.03.01
Care and treatment are planned to ensure that they are appropriate to the patient’s needs and
severity of disease, condition, impairment, or disability. Care is planned and provided in an
interdisciplinary, collaborative manner by qualified individuals.
Finding
On interview with the care team, there appears to be an interdisciplinary, collaborative process
in place within the hospital. This process, however, does not generate an interdisciplinary plan
of care. There was insufficient evidence that care goals were prioritized based on the patient’s
progress. The patient’s progress should periodically be evaluated against care goals and the
plan of care and, when indicated, the plan or goals should be revised.
PC.01.01.07
Pain is assessed in all patients.
Finding
In outpatient rehabilitation, the initial assessment of pain does not indicate the severity of the
pain, making assessment of the relief of pain as a result of treatment difficult.
PC.02.03.01
The hospital provides patient education and training based on each patients needs and
abilities.
Finding
When visiting the oncology clinic, it was noted that the medical record of the clinic patient did
not contain documented evidence that the patient’s ability/readiness to learn, learning
preference, or educational needs were assessed. The closed and open medical records reviewed
in the hospital lacked sufficient evidence that the individual’s ability to learn, prior to the
provision of education, was assessed.
RC.02.01.03
The patients medical record documents operative and other high-risk procedures and the use
of moderate or deep sedation or anesthesia.
Finding
An operative progress note was not evident in 2 of 21 closed medical records.
LD.04.01.05
The hospital effectively manages its programs, services, sites, or departments
Finding
It was evidenced through interview with three staff nurses that the leaders had not effectively
communicated to the nursing staff the policy related functional screening criteria. Interview of
three staff nurses revealed that they were not aware of the functional screening process the
hospital had implemented.
PC.03.01.01
The hospital plans operative or other high-risk procedures, including those that require the
administration of moderate or deep sedation or anesthesia.
Finding
Two medical records of patients who had undergone cardiac catherization did not contain
documentation that the patients were reevaluated immediately before the administration of
moderate sedation. In addition, a medical record of a patient receiving care in the endoscopy
area was reviewed. This record review also indicated that the patient was not reevaluated
immediately prior to the administration of moderate sedation.
Safety Reports
NPSG 1: Improving accuracy of patient identification
Opportunities for improvementuse of two patient
identifiers and labeling of specimens in the presence of
the patient
NPSG 2: Improving effectiveness of communication
Critical Results
Hospital-wide Compliance of Reporting Critical Results
within 60 Minutes as Evidenced by Documentation
NPSG 2: Improving effectiveness of communication
Verbal Orders/Read-backs
NPSG 2: Improving effectiveness of communication
Unacceptable Abbreviations
99.6%
NPSG 3: Improving safety of using medications
Labeling of containers
NPSG 3: Improving safety of using medications
Reduce the likelihood of patient harm associated
with the use of anticoagulation therapy
NPSG 7: Reduce the risk of health care-associated
infectionsHand Hygiene
Hand Hygiene Compliance
92
100
93
80
60
40
54
46
20
0
Year 1
Year 2
Year 3
Year to Date
NPSG 9: Reduce the risk of patient harm
resulting from falls
Universal Protocol
National Patient Safety Goal Data:
Communication
NPSG 2: Improving Effectiveness of Communication
Critical Results
Hospital-Wide Compliance of Reporting Critical Results within
60 Minutes as Evidenced by Documentation
JanuaryDecember
100
75
82
75
63
58
62
77 78
68
82 80
56 57
50
25
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
NPSG 2: Improving Effectiveness of Communication
Verbal Orders/Read-Backs
Verbal Order/Read Back Audits
Fiscal Year to Date
100 97
75
%
96
97
91
100 98 99
62
50
25
0
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NPSG 2: Improving Effectiveness of Communication
Unacceptable Abbreviations
99.6%
Universal Protocol
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