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WGU AFT 2 TASK
1,2,3&4 Latest
updated version
with 100% accuracy
Emmanuella Otabil
Accreditation Audit (AFT2) - Task 1
Western Governors University
, November 09, 2025
A. Compliance Status
Healthcare organizations are regulated by rigorous
standards and are held to an exceedingly high standard of
providing safe and high-quality services. The Joint
Commission is one of the governmental authorities in charge
of regulating and inspecting healthcare facilities. The Joint
Commission standards serve as the framework for an
impartial assessment procedure that can assist healthcare
organizations in measuring, assessing, and improving
performance. These criteria are centered on organizational
functions that are critical for providing safe, high-quality
care. The Joint Commission will undertake routine audits of
healthcare institutions to ensure compliance in a variety of
areas. I've decided to undertake a communication audit for
task 1.
In preparation for an approaching Joint Commission (JC) accreditation
audit, Nightingale
Community Hospital undertook an internal evaluation of
three JC standards relating to National Patient Safety Goals
,and communication measures within the institution.
UP.01.01.01 executes a pre-procedure verification process,
UP.01.02.01 marks the procedure location, and UP.01.03.01
a time-out is done before the procedure is the JC standards
that were evaluated. During the review, NCH's compliance
team examined all performance aspects relating to these
standards to determine the organization's compliance and
to provide a corrective action plan for any performance
elements found to be out of compliance. The table below
summarizes NCH's current compliance status for each
performance element as defined by JC standards
UP.01.01.01,
UP.01.02.01, and UP.01.03.01.
Standard Element of Performance Compliance
Status
UP.01.01.01 “Declares the need for a pre- NCH is in
EP1 procedure verification step. A pre- compliance
procedure process that confirms and
verifies the right procedure, patient,
and procedure location must be in
place.”
, UP.01.01.02 “Identify all of the items that must be NCH is not
EP2 available for the process and use a in
standardized list to validate their compliance
availability (necessary documentation,
labeled diagnostic and radiological
test results, any required blood
products, implants, devices, and/or
specific procedure equipment).”
UP.01.01.03 “Match the items that will be available NCH is not
EP3 to the patient in the procedure area.” in
compliance
UP.01.02.01 “Identify those procedures that require NCH is in
EP1 marking of the incision or insertion site. compliance
At a minimum,
sites are marked when there is more
than one possible location for the
procedure and when
performing the procedure in a
different location would negatively
affect quality or safety” (TJC, 2021)
UP.01.02.01 “Mark the procedure's site before the NCH is in
EP2 procedure and, if possible, with the compliance
patient present” (TJC, 2021).
UP.01.02.01 “A licensed independent practitioner, NCH is not
EP3 who is ultimately accountable for the in
procedure and will be present when it compliance
is conducted, marks the procedure
site.”
UP.01.02.01 “The method of marking the site and NCH is in
EP4 the type of mark is unambiguous and compliance
EMAIL:1
WGU AFT 2 TASK
1,2,3&4 Latest
updated version
with 100% accuracy
Emmanuella Otabil
Accreditation Audit (AFT2) - Task 1
Western Governors University
, November 09, 2025
A. Compliance Status
Healthcare organizations are regulated by rigorous
standards and are held to an exceedingly high standard of
providing safe and high-quality services. The Joint
Commission is one of the governmental authorities in charge
of regulating and inspecting healthcare facilities. The Joint
Commission standards serve as the framework for an
impartial assessment procedure that can assist healthcare
organizations in measuring, assessing, and improving
performance. These criteria are centered on organizational
functions that are critical for providing safe, high-quality
care. The Joint Commission will undertake routine audits of
healthcare institutions to ensure compliance in a variety of
areas. I've decided to undertake a communication audit for
task 1.
In preparation for an approaching Joint Commission (JC) accreditation
audit, Nightingale
Community Hospital undertook an internal evaluation of
three JC standards relating to National Patient Safety Goals
,and communication measures within the institution.
UP.01.01.01 executes a pre-procedure verification process,
UP.01.02.01 marks the procedure location, and UP.01.03.01
a time-out is done before the procedure is the JC standards
that were evaluated. During the review, NCH's compliance
team examined all performance aspects relating to these
standards to determine the organization's compliance and
to provide a corrective action plan for any performance
elements found to be out of compliance. The table below
summarizes NCH's current compliance status for each
performance element as defined by JC standards
UP.01.01.01,
UP.01.02.01, and UP.01.03.01.
Standard Element of Performance Compliance
Status
UP.01.01.01 “Declares the need for a pre- NCH is in
EP1 procedure verification step. A pre- compliance
procedure process that confirms and
verifies the right procedure, patient,
and procedure location must be in
place.”
, UP.01.01.02 “Identify all of the items that must be NCH is not
EP2 available for the process and use a in
standardized list to validate their compliance
availability (necessary documentation,
labeled diagnostic and radiological
test results, any required blood
products, implants, devices, and/or
specific procedure equipment).”
UP.01.01.03 “Match the items that will be available NCH is not
EP3 to the patient in the procedure area.” in
compliance
UP.01.02.01 “Identify those procedures that require NCH is in
EP1 marking of the incision or insertion site. compliance
At a minimum,
sites are marked when there is more
than one possible location for the
procedure and when
performing the procedure in a
different location would negatively
affect quality or safety” (TJC, 2021)
UP.01.02.01 “Mark the procedure's site before the NCH is in
EP2 procedure and, if possible, with the compliance
patient present” (TJC, 2021).
UP.01.02.01 “A licensed independent practitioner, NCH is not
EP3 who is ultimately accountable for the in
procedure and will be present when it compliance
is conducted, marks the procedure
site.”
UP.01.02.01 “The method of marking the site and NCH is in
EP4 the type of mark is unambiguous and compliance
