The Joint Commission requires a root cause analysis for all sentinel events. These analyses can be of enormous value. They capture both the big-picture perspective and the details. They facilitate system evaluation, analysis of need for corrective action, and tracking and trending. Managers will be able to determine how often a particular error occurs or how often a particular floor or unit of the hospital is involved. This information may provide clues to the problem. A root cause analysis is very useful and important especially in near-miss scenarios. The technique is applicable not only to laboratory medicine but also to other healthcare-associated disciplines.
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Task:
A.  Conduct a root cause analysis of the sentinel event found in the attached Accreditation Audit Case Study – Task 2 Artifacts by doing the following:
1.  Describe the sentinel event.
2.  Explain the roles (i.e. responsibilities, etc.) of the personnel present during the sentinel event.
3.  Discuss the barriers that may impede effective interaction among the personnel present during the sentinel event.
a.  Propose ways to improve interactions among the personnel present.
4.  Discuss a quality improvement tool to be used to conduct the root cause analysis.
B.  Outline a corrective action plan to ensure that the sentinel event does not recur by doing the following:
1.  Recommend a risk management program or process change to ensure that the sentinel event does not recur.
a.  Discuss resources available to support these changes.
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In this task, you will use a tracer methodology to track a patient’s care in order to evaluate the healthcare organization’s systems of providing care and services for a readiness audit. This methodology also makes it possible to assess the healthcare organization’s compliance with Joint Commission standards. This is part of the organization’s compliance with delivering safe, quality healthcare.
You will examine data for a patient that is found in the attached “Accreditation Audit Case Study – Task 3 Artifacts” and find any trends, patterns, and problems. Once these have been identified, you can remediate the concerns.
Task:
A.  Review the tracer patient information from the attached Accreditation Audit Case Study – Task 3 Artifacts and do the following:

1.  Discuss an outstanding patient care issue for the organization made evident by the tracer patient.

2.  Develop a corrective action plan to address the patient care improvement needs for the organization using a keyword search in the Joint Commission electronic manual.
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.
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Task:
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.
2.  Discuss any 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