...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 fallout...
Words: 3108 - Pages: 13
...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...
Words: 2777 - Pages: 12
...WGU AFT2 RAFT2 (Accreditation Audit) MBA Graduate Programe - Complete Course All 4 Tasks http://www.homeworkminutes.com/question/view/41054/AFT2-RAFT2-Accreditation-Audit-WGU-MBA-Graduate-Program-Complete-Course 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 were...
Words: 982 - Pages: 4
...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 these...
Words: 2426 - Pages: 10
...White Paper Understanding NIST 800‐37 FISMA Requirements Contents Overview ................................................................................................................................. 3 I. The Role of NIST in FISMA Compliance ................................................................................. 3 II. NIST Risk Management Framework for FISMA ..................................................................... 4 III. Application Security and FISMA .......................................................................................... 5 IV. NIST SP 800‐37 and FISMA .................................................................................................. 6 V. How Veracode Can Help ...................................................................................................... 7 VI. NIST SP 800‐37 Tasks & Veracode Solutions ....................................................................... 8 VII. Summary and Conclusions ............................................................................................... 10 About Veracode .................................................................................................................... 11 © 2008 Veracode, Inc. 2 Overview The Federal Information Security Management Act of 2002 ("FISMA", 44 U.S.C. § 3541, et seq.) is a United States federal law enacted in 2002 as Title III of the E‐...
Words: 2451 - Pages: 10
...2 Technical Objectives 2 2.1.3 Management Objectives 3 2.2 Assumptions and Constraints 3 2.2.1 Access Control 4 2.2.2 Authentication 4 2.2.3 HSPD-12 Personnel Security Clearances 4 2.2.4 Non-Disclosure Agreements 5 2.2.5 Accessibility 5 2.2.6 Data 5 2.2.7 Confidentiality, Security, and Privacy 5 2.3 Tasks/Sub-Tasks to Be Performed Related to Initiating the Service 6 2.3.1 Task 1: 6 2.3.2 Task 2: 7 2.4 Period of Performance 7 3 PERFORMANCE MANAGEMENT OF THE DELIVERED SERVICES 8 3.1 Modifications to Service Level Agreements 8 3.2 Changes to Key Performance Measures. 8 3.3 Quality Assurance Evaluation 8 3.4 Government Roles and Responsibilities. 9 3.4.1 Contracting Officer (CO) 9 3.4.2 Contract Specialist 9 3.4.3 Contracting Officer’s Technical Representative (COTR) 10 3.4.4 Other Key Government Personnel 10 3.5 Contractor Roles and Responsibilities 10 4 METHODS OF QUALITY ASSURANCE SURVEILLANCE 11 5 SECURITY REQUIREMENTS 11 5.1 Required Policies and Regulations for GSA Contracts 11 5.2 GSA Security Compliance Requirements 13 5.3 Certification and Accreditation (C&A) Activities 13 5.3.1 Certification of System 14 5.3.2 Accreditation of System 15 5.4 Reporting and Continuous Monitoring 16 5.4.1 Deliverables to be provided to the GSA COTR/ISSO/ISSM Quarterly...
Words: 7425 - Pages: 30
...1) The DoD Information Assurance Certification and Accreditation Process (DIACAP) is the United States Department of Defense (DoD) process to ensure that risk management is applied on Information Systems from an enterprise view. DIACAP is a DoD-wide standard set of activities, tasks and process for the certification and accreditation of a DoD information system that will maintain the Information Assurance posture throughout the system's life cycle. The Department of Defense Information Technology Security Certification and Accreditation Process (DITSCAP) is a process defined by the United States Department of Defense (DOD) for managing risk. DoD Instruction (DODI) 5200.40 establishes a standard DOD-wide process with a set of activities, general tasks and a management structure to certify and accredit an Automated Information System (AIS) that will maintain the Information Assurance (IA) posture of the Defense Information Infrastructure (DII) throughout the system's life cycle. DITSCAP applies to the acquisition, operation and sustainment of any DOD system that collects, stores, transmits, or processes unclassified or classified information since December 1997. 2) The Director of Central Intelligence Directive (DCID) 6/3 establishes the security policy and procedures for storing, processing, and communicating classified intelligence data in information systems. To achieve compliance with DCID 6/3, agencies must ensure that information is safeguarded at all times and that...
Words: 360 - Pages: 2
...information security management programs, information assurance certification programs, and security ethics. Watch the following video for an introduction to this course: Competencies This course provides guidance to help you demonstrate the following 3 competencies: Competency 427.3.2: Controls and Countermeasures The graduate evaluates security threats and identifies and applies security controls based on analyses and industry standards and best practices. Competency 427.3.3: Security Audits The graduate evaluates the practice of defining and implementing a security audit and conducts an information security audit using industry best practices. Competency 427.3.4: Certifications and Accreditations The graduate identifies and discusses the Information Assurance certification and accreditation (C&A) process. Course Mentor Assistance As you prepare to successfully demonstrate competency in this subject, remember that course mentors stand ready to help you reach your educational goals. As subject matter experts, mentors enjoy and take pride in helping...
Words: 4354 - Pages: 18
...Accreditation Audit: AFT Task 3 Western Governor’s University Abstract AFT Task 3 allows the examination of data from a patient while hospitalized at Nightingale Hospital and utilizes a tracer methodology to identify trends, patterns, and pertinent problems for healthcare improvement. We plan to develop a corrective action plan to address the organization’s improvement while maintaining compliance from a Joint Commission standard. Accreditation Audit: AFT Task 3 Nightingale Hospital is preparing to devise a mock tracer methodology to assess the organizations’ current compliance with Joint Commission Standards. A tracer methodology follows a patient through the course of care and evaluates all aspects of care (Joint Commission E-dition, 2014). This method allows a quick overview of a patient through the flow of a system in order to evaluate the effectiveness of the process flow. Our mock tracer patient is a sixty seven year old female whom recently underwent an open total abdominal hysterectomy secondary to menorrhagia and uterine fibroids. The patient presented back to the emergency room one week postoperatively with complaints of a subjective fever of 100.2 degrees Fahrenheit and incisional drainage described as yellowish-green in color. A CT scan of her abdomen was performed in the emergency room and revealed a peri-umbilical abscess. The surgical team was consulted and an incision and drainage of the abscess was performed. Infectious disease physicians determined...
Words: 528 - Pages: 3
...Accreditation Audit: AFT2 task 2 1 Accreditation Audit: AFT2 Task 2 Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process. Accreditation Audit: AFT2 task 2 2 Analysis of Key Components RCA: Child Abduction Please note that the root cause analysis and action plan must show evidence of an analysis within the key components as outlined on the root cause analysis matrix for the specific type of event. An area on the matrix that may not have an identified process breakdown should still be summarized to determine that the component was evaluated. Brief description of event Briefly summarize the circumstances surrounding the occurrence including the patient outcome (e.g., death, loss of function). A 3-‐year-‐old female pediatric patient...
Words: 3407 - Pages: 14
...Assurance Certification and Accreditation Process (DIACAP) (a) Subchapter III of Chapter 35 of title 44, United States Code, “Federal Information Security Management Act (FISMA) of 2002” (b) DoD Directive 8500.01E, “Information Assurance (IA),” October 24, 2002 (c) DoD Directive 8100.1, “Global Information Grid (GIG) Overarching Policy,” September 19, 2002 (d) DoD Instruction 8500.2, “Information Assurance (IA) Implementation,” February 6, 2003 (e) through (ab), see Enclosure 1 1. PURPOSE This Instruction: 1.1. Implements References (a), (b), (c), and (d) by establishing the DIACAP for authorizing the operation of DoD Information Systems (ISs). 1.2. Cancels DoD Instruction (DoDI) 5200.40; DoD 8510.1-M; and ASD(NII)/DoD CIO memorandum, “Interim Department of Defense (DoD) Information Assurance (IA) Certification and Accreditation (C&A) Process Guidance” (References (e), (f), and (g)). 1.3. Establishes or continues the following positions, panels, and working groups to implement the DIACAP: the Senior Information Assurance Officer (SIAO), the Principal Accrediting Authority (PAA), the Defense Information Systems Network (DISN)/Global Information Grid (GIG) Flag Panel, the IA Senior Leadership (IASL), the Defense (previously DISN) IA Security Accreditation Working Group (DSAWG), and the DIACAP Technical Advisory Group (TAG). 1.4. Establishes a C&A process to manage the implementation of IA capabilities and services and provide visibility of accreditation decisions regarding the operation...
Words: 16882 - Pages: 68
...Review Questions for Chapter 7 – Security Management Practices Read Chapter 7 in the text, Study the Power Point Presentation and answer these Review Questions 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. What is benchmarking? What is the standard of due care? How does it relate to due diligence? What is a recommended security practice? What is a good source for finding such best practices? What is a gold standard in information security practices? Where can you find published criteria for it? When selecting recommended practices, what criteria should you use? When choosing recommended practices, what limitations should you keep in mind? What is baselining? How does it differ from benchmarking? What are the NIST-recommended documents that support the process of baselining? What is a performance measure in the context of information security management? What types of measures are used for information security management measurement programs? According to Dr. Kovacich, what are the critical questions to be kept in mind when developing a measurements program? What factors are critical to the success of an information security performance program? What is a performance target, and how is it used in establishing a measurement program? Answer: Performance targets are values assigned to specific metrics that indicate acceptable levels of performance. They make it possible to define success in the security program. 14. 15. List and describe the fields found in a properly and fully...
Words: 1387 - Pages: 6
...Accreditation Audit AFT2 Task 1. Herman Big Mawanda Western Governors University Contents COMPLIANCE STATUS. 3 PLANS OF COMPLIANCE 7 JUSTIFICATION 8 BIBLIOGRAPHY 10 Nightingale Community Hospital provides leadership in quality health services. Its core values focus on safety, community, teamwork and accountability with a vision of being a hospital of choice for all and a mission to create a healing environment with a passionate commitment to health care excellence. This executive summary of the accreditation audit is presented to the senior leadership to outline the compliance, plan of compliance and institution of the hospital under the reviewed focus area of Information Management as per the Joint Commission Standards. COMPLIANCE STATUS. The Joint Commission Standard IM 02.02.01 requires that the hospital effectively manages the collection of health information. Nightingale Community Hospital is in compliance with this standard under its patient care policy which specifies prohibited abbreviations. Its policy states that the use of abbreviations and symbols in the medical record is discouraged to prevent errors; as these can be associated with misinterpretation resulting in medical errors, and patient harm. In case the intended meaning of the abbreviation or symbol in the context of a specific order is not clear, the ordering practitioner must be contacted for clarification. This procedure demands that the elements of performance under IM 02.02.01 of the...
Words: 1726 - Pages: 7
...The Joint Commission is a nonprofit organization that certifies more than 18,000 health care organization and programs throughout the world. Founded in 1951, the Joint Commission provides a national symbol of quality for health care as well as analyzes each organization’s commitment to meeting high quality performance standards. The Joint commission focuses on accrediting Acute Care Hospitals, ambulatory, behavior health, long term care, health care facilities, clinical laboratories, health care networks and hospice. Numerous of accreditation organization is also taking place within the United States, but the Joint commission remains the largest The Joint commission accredits 20,000 organization” which” one third are Hospitals. The joint commission is assigned a special task to improve health care by evaluating health care of organization as well as encouraging health organizations to provide safe and effective care at the highest level. The Joint Commission believes that the only way to improve the quality of health care is to join together with other stakeholders and evaluate each health care organization. The Stakeholder consists of 29 broad members of commissioner and cooperate members such as the American Hospital Association, and the American Medical Association. In this paper I will analyzes key topics such as the Joint Commission source and its scope of authority, the structure of the Joint commission and how its responsibilities. The Joint Commission Structure ...
Words: 1282 - Pages: 6
...Nightingale Community Hospital is compliant with The Joint Commission standards except the following areas: Accreditation function of environment of care and life safety, it was documented that more than 3 smoke wall penetrations were found on the 1st floor and one on the 4th floor. The hospital is to minimize the potential for harm from fire, and smoke (TJC, 2013). A review of documentation showed appropriate ILSM was not initiated during 3 construction projects this put employees and patients at risk. Education of fire safety equipment should have been completed before the project. The gift shop did not have the required 18 inch clearance from the sprinklers. All sprinklers must have at least 18 inches below and around of clearance for The Joint Commission standards. Review of department documentation shows that the master alarm panel for medical gasses was not tested annually per policy. This is a policy written by the hospital that is not being met. They are to follow the policies that they set for themselves. The Fire Drill History Report showed that the fire drill process is not adequate and does not meet standards. Quarterly fire drills are to be conducted as regulated by the Life Safety Code (TJC, 2013). Clutter was found in the hallways of 3E, 4E, OR and telemetry this could restrict people from leaving the floor safely in case of fire or smoke. Accreditations function of Nursing Leadership it was discovered that Nurses on 3E were not documenting in a timely manner....
Words: 2356 - Pages: 10
