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.
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.
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. The originality report that is provided when you submit your task 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.
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 by including the compliance status of each of the 18 Joint Commission standard focus areas.
2. Discuss at least two 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. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.
C. Demonstrate professional communication in the content and presentation of your submission.