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 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. Write a sentence or two why these 18 Joint Commission standard focus areas are important (See attached “The Joint Commission Standards_Accreditation Requirements”). Also, the compliant areas in the attached “FSA findings” are APR, HR, IC, PI, RI, TS, and WT. Write a sentence or two why they are important. The ones that are NOT in compliance (highlighted in blue, see attached “The Joint Commission Standards_Accreditation Requirements”), just give an example from the “FSA Findings” of each area why they are not in compliance.
2. Discuss at least two trends evident in the Accreditation Audit Case Study Artifacts that may cause the organization to not be compliant with the Joint Commission standards for patient care. Review the attached “Moderate Sedation Audit”, “Pain Reassessment Audit”, “Prohibited Abbreviation Audit”, and “Verbal Order Audit” to identify at least 2 trends 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 (review the attached “Staffing Effectiveness Report”):
a. Analyze the data to determine the staffing patterns of the patient care unit. You must paint a picture in narrative form of all the graphs for 3E, 4E and ICU so that you can discuss what you see and compare the information for the three areas. Provide a narrative of what you see for the falls for 3E, 4E, and ICU.
b. Develop a staffing plan to minimize the number of falls in the patient care unit. You need to include a plan of how you will handle minimizing the falls and then in a table indicate how many RNs, LPNs, CNAs (or whatever you want your mix to be) to handle the day, evening, and midnight shifts. And why is that mix will help to minimize those falls.
B. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized. APA format.
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