Develop a corrective action plan that would ensure compliance with the Joint Commission standards for the identified area.
COMPETENCIES
705.2.4 : Regulatory Audits
The graduate ensures a healthcare organization is in compliance with mandatory regulatory audit guidelines pertaining to the organization.
705.4.3 : Compliance
The graduate identifies and helps a healthcare organization comply with applicable healthcare statutes and regulations.
INTRODUCTION
In this task, you are preparing for an accreditation audit. There are many variables that must be considered to ensure compliance with Joint Commission standards. In order for the audit to be successful, you must be aware of the accrediting agency’s guidelines.
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. 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. 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.
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.
File Restrictions
File name may contain only letters, numbers, spaces, and these symbols: ! – _ . * ‘ ( )
File size limit: 200 MB
File types allowed: doc, docx, rtf, xls, xlsx, ppt, pptx, odt, pdf, txt, qt, mov, mpg, avi, mp3, wav, mp4, wma, flv, asf, mpeg, wmv, m4v, svg, tif, tiff, jpeg, jpg, gif, png, zip, rar, tar, 7z
RUBRIC
A:COMPLIANCE STATUS
NOT EVIDENT
The candidate does not provide an executive summary outlining the current compliance status of the organization based on the attached “Accreditation Audit Case Study” for 1 area of the Joint Commission standards.
APPROACHING COMPETENCE
The candidate provides an executive summary, with insufficient detail, outlining the current compliance status of the organization based on the attached “Accreditation Audit Case Study” for 1 area of the Joint Commission standards.
COMPETENT
The candidate provides an executive summary, with sufficient detail, outlining the current compliance status of the organization based on the attached “Accreditation Audit Case Study” for 1 area of the Joint Commission standards.
A1:PLAN FOR COMPLIANCE
NOT EVIDENT
The candidate does not develop a corrective action plan that would ensure compliance with the Joint Commission standards for the identified area.
APPROACHING COMPETENCE
The candidate develops a corrective action plan, with insufficient detail, that would ensure compliance with the Joint Commission standards for the identified area.
COMPETENT
The candidate develops a corrective action plan, with sufficient detail, that would ensure compliance with the Joint Commission standards for the identified area.
A2:JUSTIFICATION
NOT EVIDENT
The candidate does not provide a logical justification of why the selected priority focus area is important to the hospital.
APPROACHING COMPETENCE
The candidate provides a logical justification, with insufficient support, of why the selected priority focus area is important to the hospital.
COMPETENT
The candidate provides a logical justification, with sufficient support, of why the selected priority focus area is important to the hospital.
B:SOURCES
NOT EVIDENT
The submission does not include both in-text citations and a reference list for sources that are quoted, paraphrased, or summarized.
APPROACHING COMPETENCE
The submission includes in-text citations for sources that are quoted, paraphrased, or summarized and a reference list; however, the citations or reference list is incomplete or inaccurate.
COMPETENT
The submission includes in-text citations for sources that are properly quoted, paraphrased, or summarized and a reference list that accurately identifies the author, date, title, and source location as available.
C:PROFESSIONAL COMMUNICATION
NOT EVIDENT
Content is unstructured, is disjointed, or contains pervasive errors in mechanics, usage, or grammar. Vocabulary or tone is unprofessional or distracts from the topic.
APPROACHING COMPETENCE
Content is poorly organized, is difficult to follow, or contains errors in mechanics, usage, or grammar that cause confusion. Terminology is misused or ineffective.
COMPETENT
Content reflects attention to detail, is organized, and focuses on the main ideas as prescribed in the task or chosen by the candidate. Terminology is pertinent, is used correctly, and effectively conveys the intended meaning. Mechanics, usage, and grammar promote accurate interpretation and understanding.
Requirements: 5 pages
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