Wgu Accreditation Audit Aft2 Task 3

992 WordsSep 14, 20154 Pages
Tracer Patient Audit AFT2 Accreditation Audit October 10th, 2014 Tracer Patient Audit With an audit by the Joint Commission (JC) in the near future, Nightingale Community Hospital (NCH) is performing a tracer patient survey to measure our compliance and identify issues that are in need of remediation. The practice of this type of survey tracks a patient’s care for the duration of their stay starting from the admission process and ending when they are discharged. This system allows us to assess our strengths and weaknesses concerning policy, procedures, and systems in place to provide quality care in conjunction with the standards set forth by the JC. Summary of Tracer Patient Audit Findings This particular…show more content…
The portion of the action plan consists of two main parts 1. Give all personnel a written update to this policy as soon as it is updated 2. Nurse supervisors will conduct group training sessions to go over this new policy and procedure, and accompanying forms a. Have all employees sign an acknowledgement form that they understand the new policy and corresponding procedures, and received training within 14 days of establishment of the new policy The third part of the action plan will be to assess the progress of changes. This requires measuring current and future performance against past performance, which will need to be assessed more in depth than the initial tracer patient audit. The last portion of the corrective action plan not only assesses the change, but might also include further revisions to the change in policy and procedures if it is found that performance is inconsistent with the standards set forth by the Joint Commission. The part of the plan has four parts that consist of: 1. Conduct a randomized audit of the past 60 days prior to policy change to ascertain the percentage of compliance before the change in policy for future comparative analysis 2. Follow up over the course of 30 days for

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