Topic: HCOA: Part 3
Order Description
Part Three: Facility Safety and Emergency Management
2 part assignment:
part 1.
You will conduct an assessment on the last of the 5
components of the assessment: Facility Safety and Emergency
Management, and you will review the entire assessment and develop
an action plan to address 1 area of concern.
You will assess and score each component, and provide supporting
data such as name and title of interviewee, and date of interview,
and/or title and number of policy. You will write an assessment of
each component and identify any strengths or gaps.
You will review the entire assessment document (all 5 areas
of assessment).You will identify areas with gaps or needs to
strengthen the findings to meet the standard.
Part 2.
Of the identified component of need, you will select 1
component and write an action plan. The action plan should be 1–2
pages long and utilize the format listed on page 85 of the
assessment template. The action plan should include 3–5 resources
documented in current APA format along with a reference page. All
assignments should contain a title page. This assignment will be
submitted via Safe Assign.
Murfreesboro Veterans Affairs Medical Center (MVAMC) is the facility the assessment will be completed on with the plan of actionthe
HEALTH CARE ORGANIZATIONAL ASSESSMENT INSTRUCTIONS
An organizational assessment is an important tool to ensure
the organization is meeting standards, and identifying gaps to
improve quality, safety, services, the work place environment, and
patient outcomes. This assignment utilizes the International
Finance Corporation’s Self-Assessment Guide for Health Care
Organizations located in the Reading & Study folder in
Module/Week 2 (used with permission from the International Finance
Corporation/World Bank Group). NOTE: Views expressed by the
International Finance Corporation
The assessment template is a guide for assessment. It is only
a guide and provides a framework to assess organizations against
the International Joint Commission’s standards. It will provide the
framework for this assignment. There are other tools, but for this
assignment, this aforementioned tool will be used. If you were
conducting a full organization’s assessment, it is recommended you
work as a team. For this assignment, you will collect the data
independently through review of internal and external data, and
interviews with key personnel such as the Chief Nursing Officer,
Risk Manager, Unit Managers, etc. as needed.
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There are 5 key components of assessment and 31 elements:
Components of the Assessment Suggested Sources
Clinical Governance and Leadership (CGL) Each organization is
structured somewhat differently, below are some suggested sources
for the information you need to complete this assignment.
Clinical Governance and Leadership:
Consider interviews with legal department, Vice President,
Director, Chief Nursing Officer, Unit Manager, Review policies and
procedures manuals for all sections of the assessment, also the
safety manual is helpful.
• Governance documents
• Management responsibility for operations
• Oversight of contracts
• Departmental scope of services and policies and procedures
• Space and equipment planning
• Staff recruitment, retention and development Interview
Retention and Recruitment Nurse if available or HR representative
Ethics and Patient Rights (EPR) Review Policies and
Procedures (Note: not all organizations participate in organ
transplantation, pregnancy termination, etc., write NA to indicate
the service is not available if not offered at the organization
assessed. Also consider interviewing members of the Ethics
Committee, Chaplains or unit specific managers for specific
services, interview the medical staff credentialing department
members, nursing research council members, Institutional Review
Board Chair for research.
• Verification of professional staff credentials
• Processes to support patient and family rights
• Informed consent
• Framework for ethical management
• Organ and tissue donation
• Reproductive health policies/IVF
• Termination of pregnancy services
• Clinical research
Quality Measurement and Improvement (QMI) Review Policies and
Procedures, interview nurse leaders, members of the Process
Improvement or QMI team, staff nurses, risk management, and nursing
governance board members
• Clinical practice guidelines and pathways
• Leaders’ involvement and support
• Infection prevention and control
• Medications use
• Sentinel events
Patient Safety (PS) Review Policies and Procedures, Interview
Nursing Leaders, staff nurses, pharmacy, operating services
leaders, infection control nurses, safety team members or others
involved in patient safety initiatives
• Patient identification
• Effective communication
• High alert medications
• Correct site, procedure, and patient for surgery
• Health care associated infections
• Risk of falls
Facility Safety and Emergency Management (FSE) Review
Policies and Procedures¬-consider interviewing the safety officer
or leader responsible for plant management, safety officer
• Environmental safety and security
• Hazardous materials plan
• Emergency management planning
• Fire/smoke plans
• Medical equipment maintenance
• Utilities management
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Getting Started:
Step 1: Read the Introduction
Step 2: Read “Preparing for the Self-Assessment”
Step 3: Complete the required information—your name,
organization’s name, address, date, etc. Note: While conducting
this assessment it is understood that some institutions may protect
certain budget or other information; however, policies should be
available and should provide adequate information along with
interview to complete the assessment.
Step 4: Assess the assigned section and each component
carefully. Utilize the aforementioned resources to assess the
component such as interview and review of policies and procedures.
Document the title and number of each policy reviewed and cite in
current APA format the interview. Then score each component
according to the following scoring scale. Write a brief overview of
your findings; include any strengths or gaps identified for each
component.
Score each section on the form after reviewing the policies
and procedures pertinent to that area and or conducting an
interview.
Scoring Key: 0 = the organization does not meet the
component
5 = yes, some elements are in place, but the component is
not fully satisfied
10 = yes, the component is fully satisfied
(Note: A baseline scoring table is located at the end of
the assessment tool—this will not be used for this exercise, but
may be used for tracking multiple assessments and progression of
the organization).
Part 1: Clinical Governance and Leadership and Ethics and
Patient Rights
You will utilize the Self-Assessment Guide for Health Care
Organizations Assessment to complete this assignment. You will read
the introduction and preparing for the self-assessment prior to
completing the assignment. Part 1 consists of the student
conducting an assessment on 2 of the 5 components of the
assessment: Clinical Governance and Leadership, and Ethics and
Patient Rights. You will assess and score each component and
provide supporting data such as name and title of interviewee, date
of interview, and/or title and number of policy. You will write an
assessment of each component and identify any strengths or gaps. A
title page must be included with this assignment and not only
include your name, but the name and address of the organization.
This assignment will be submitted via Safe Assign by 11:59 p.m.
(ET) on Sunday of Module/Week 2.
Part 2: and Improvement and Patient Safety
You will conduct an assessment on 2 of the 5 components of
the assessment: Quality Measurement and Improvement and Patient
Safety. You will assess and score each component, and provide
supporting data such as name and title of interviewee, date of
interview, and/or title and number of policy. You will write an
assessment of each component and identify any strengths or gaps. A
title page must be included with this assignment and not only
include your name, but the name and address of the organization.
This assignment will be submitted via Safe Assign by 11:59 p.m.
(ET) on Sunday of Module/Week 3.
Part Three: Facility Safety and Emergency Management
You will conduct an assessment on the last of the 5
components of the assessment: Facility Safety and Emergency
Management, and you will review the entire assessment and develop
an action plan to address 1 area of concern.
You will assess and score each component, and provide
supporting data such as name and title of interviewee, and date of
interview, and/or title and number of policy. You will write an
assessment of each component and identify any strengths or gaps.
You will review the entire assessment document (all 5 areas
of assessment).You will identify areas with gaps or needs to
strengthen the findings to meet the standard. Of the identified
component of need, you will select 1 component and write an action
plan. The action plan should be 1–2 pages long and utilize the
format listed on page 85 of the assessment template. The action
plan should include 3–5 resources documented in current APA format
along with a reference page. All assignments should contain a title
page. This assignment will be submitted via Safe Assign.
Murfreesboro Veterans Affairs Medical Center (MVAMC) is the facility the assessment will be completed on with the plan of actionthe
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