ACCREDITATION PROCESS 1
WGU AFT2 – Task 4 |Passed on First Attempt
|Latest Update with Complete Solution
Accreditation Audit
AFT2 – Task 4
Abdul Wali Shahzad
Western Governors University
Dr. Austin Arenz
June 27, 2025
A1. Compliance Status
The accreditation process facilitates detecting known and unknown risks to patient safety
and quality of care by conducting meaningful assessments. It inspires healthcare organizations to
provide high-quality care and encourages them to improve their performance. As the director of
accreditation, I reviewed the records, previous audits, trends, and files of the Nightingale
Hospital across all departments. I assessed its current status and preparedness for the upcoming
Joint Commission audit. During my review, I compared the Hospital's current status against all
18 Joint Commission standard focus areas and found the Hospital noncompliant in 11 different
areas.
Noncompliant
• Medication Management (MM)
• National Patient Safety Goals
(NPSG)
• Environment of Care (EC)
• Life Safety (LS)
,ACCREDITATION PROCESS 2
Compliant
• Accreditation Participation
Requirements (APR)
• Human Resources (HR)
• Infection Prevention and Control (IC)
• Emergency Management (EM)
• Rights and Responsibilities of the
Individual (RI)
• Waived Testing (WT)
• Transplant Safety (TS)
• Performance Improvement (PI)
1. Accreditation Participation Requirement (APR): Compliant
This standard is assessed during the initial Joint Commission survey. Nightingale Hospital
was found to be compliant because it accurately represents its accreditation status, programs, and
services according to the Joint Commission standards. The Hospital notifies the public it serves
about how to contact its management or report a concern about the safety and quality of care of
the individual (s). The Hospital is not involved in false or misleading advertising about its
accreditation status.
2. Medication Management (MM): Noncompliant
Medication management is an essential part of patient care. Incorrect medicine or dose can
cause serious harm. During the audit, I evaluated and inspected different medical management
processes such as planning, selection and procurement, storage, ordering, preparing and
dispensing, administration, and monitoring and found the Hospital noncompliant based on the
following cases:
a. During my interview with a staff member on the 4E-1st floor, I noticed that the nurse did
not follow the range order policy, and, in another interview with the ICU nurse, she could
, ACCREDITATION PROCESS 3
not explain how the range dose policy is executed. This is a direct violation of the Joint
Commission standard MM 04.01.01, which states that "there must be a documented
indication for all ordered medications."
b. In another instance, during the PPR rounds in the OR, I found the Propofol syringes
unlabeled. This has a direct impact on patient health care and is a violation of Joint
Commission standards MM.05.01.09 and NPSG.03.04.01
3. Human Resources (HR): Compliant
The Nightingale Hospital was compliant with the Joint Commission HR standard. The
Hospital had clear job descriptions, and the staff possessed current active licenses, certifications,
or registrations according to the state law. The staff was found competent to perform their jobs,
and their competency was assessed and documented once every year. The documents also showed
that the Hospital had provided sufficient orientation to the staff about the sensitivity to cultural
diversity issues.
4. National Patient Safety Goals (NPSG): Noncompliant
The National Patient Safety Goals focus on accurate patient identification, medication
safety, infection prevention, alarm safety, effective communication, health care equity, and suicide
risk. Adapting to these goals is important for a more effective and safe healthcare environment
(TJC, 2025). The Hospital was found noncompliant with the NPSG.03.04.01 standard states, "All
medications, medication containers, and other solutions on and off the sterile field in perioperative
or other procedural settings must be labeled." During my PPR round in the OR, I found unlabeled
basins, and, in another instance, I observed prelabeled syringes in cataract packs from an external
supplier.
5. Infection Prevention and Control (IC): Compliant
The infection prevention and control activities at Nightingale Hospital were reasonable.
Hand sanitizer gel was available in all common areas. Antibiotics were ordered cautiously, and
strict attention was paid to antibiotic resistance. The Hospital offers on-site and off-site vaccination
WGU AFT2 – Task 4 |Passed on First Attempt
|Latest Update with Complete Solution
Accreditation Audit
AFT2 – Task 4
Abdul Wali Shahzad
Western Governors University
Dr. Austin Arenz
June 27, 2025
A1. Compliance Status
The accreditation process facilitates detecting known and unknown risks to patient safety
and quality of care by conducting meaningful assessments. It inspires healthcare organizations to
provide high-quality care and encourages them to improve their performance. As the director of
accreditation, I reviewed the records, previous audits, trends, and files of the Nightingale
Hospital across all departments. I assessed its current status and preparedness for the upcoming
Joint Commission audit. During my review, I compared the Hospital's current status against all
18 Joint Commission standard focus areas and found the Hospital noncompliant in 11 different
areas.
Noncompliant
• Medication Management (MM)
• National Patient Safety Goals
(NPSG)
• Environment of Care (EC)
• Life Safety (LS)
,ACCREDITATION PROCESS 2
Compliant
• Accreditation Participation
Requirements (APR)
• Human Resources (HR)
• Infection Prevention and Control (IC)
• Emergency Management (EM)
• Rights and Responsibilities of the
Individual (RI)
• Waived Testing (WT)
• Transplant Safety (TS)
• Performance Improvement (PI)
1. Accreditation Participation Requirement (APR): Compliant
This standard is assessed during the initial Joint Commission survey. Nightingale Hospital
was found to be compliant because it accurately represents its accreditation status, programs, and
services according to the Joint Commission standards. The Hospital notifies the public it serves
about how to contact its management or report a concern about the safety and quality of care of
the individual (s). The Hospital is not involved in false or misleading advertising about its
accreditation status.
2. Medication Management (MM): Noncompliant
Medication management is an essential part of patient care. Incorrect medicine or dose can
cause serious harm. During the audit, I evaluated and inspected different medical management
processes such as planning, selection and procurement, storage, ordering, preparing and
dispensing, administration, and monitoring and found the Hospital noncompliant based on the
following cases:
a. During my interview with a staff member on the 4E-1st floor, I noticed that the nurse did
not follow the range order policy, and, in another interview with the ICU nurse, she could
, ACCREDITATION PROCESS 3
not explain how the range dose policy is executed. This is a direct violation of the Joint
Commission standard MM 04.01.01, which states that "there must be a documented
indication for all ordered medications."
b. In another instance, during the PPR rounds in the OR, I found the Propofol syringes
unlabeled. This has a direct impact on patient health care and is a violation of Joint
Commission standards MM.05.01.09 and NPSG.03.04.01
3. Human Resources (HR): Compliant
The Nightingale Hospital was compliant with the Joint Commission HR standard. The
Hospital had clear job descriptions, and the staff possessed current active licenses, certifications,
or registrations according to the state law. The staff was found competent to perform their jobs,
and their competency was assessed and documented once every year. The documents also showed
that the Hospital had provided sufficient orientation to the staff about the sensitivity to cultural
diversity issues.
4. National Patient Safety Goals (NPSG): Noncompliant
The National Patient Safety Goals focus on accurate patient identification, medication
safety, infection prevention, alarm safety, effective communication, health care equity, and suicide
risk. Adapting to these goals is important for a more effective and safe healthcare environment
(TJC, 2025). The Hospital was found noncompliant with the NPSG.03.04.01 standard states, "All
medications, medication containers, and other solutions on and off the sterile field in perioperative
or other procedural settings must be labeled." During my PPR round in the OR, I found unlabeled
basins, and, in another instance, I observed prelabeled syringes in cataract packs from an external
supplier.
5. Infection Prevention and Control (IC): Compliant
The infection prevention and control activities at Nightingale Hospital were reasonable.
Hand sanitizer gel was available in all common areas. Antibiotics were ordered cautiously, and
strict attention was paid to antibiotic resistance. The Hospital offers on-site and off-site vaccination
