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Topic: HCOA: Part 3

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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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