PLEASE!!!! Read the question sheet attached. Understand the scenario and answer the prompts that follow in three separate sections.

Prompt 1 should be a power point presentation and should be done on the APA power point attached here.

Prompts 2 through 5 should be done on a Word document

Prompt 3 should be done on the Compliance worksheet attached here

Above all please follow the rubric and see that the responses you give EXCEED expectation 

Thank you

Access the following to complete this Assessment:

·

Compliance Issues Worksheet

Click each of the items below to complete this assessment.

Scenario

Imagine that you are an executive with a healthcare consultancy that helps hospitals improve patient experiences by creating and implementing sustainable quality improvement programs. Consider your role as you answer the questions in this Assessment.

Prompts

1. An important part of your role at the consulting firm is to lead training sessions at hospitals nationwide. At the training sessions, you educate hospital administrators on the history of the quality-management movement in healthcare. Many of the individuals you train have little or no background in quality management, and you have found that leadership is more receptive to changes if they understand the history of the quality-management movement in healthcare.

· Briefly summarize the history of the quality movement, in general, to set the context for this presentation.

· Explain the influence of Deming and Donabedian (referenced in Chapter 1 of the Varkey text) in the healthcare quality-management movement.

· Describe the impact that the two reports, To Err is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, had on quality management in the healthcare system.

· Describe the role of the Centers for Medicare & Medicaid Services (CMS) in the healthcare quality-management movement.

· Summarize the impact of The Joint Commission accreditation in the quality-improvement process of participating hospitals.

Create a PowerPoint presentation to communicate the following information to your audience. (8–10 slides)

2. As a result of your success as a healthcare-quality consultant, you have been invited to appear as a guest on a nationally syndicated news show. The show explores the topic of quality in healthcare. The interviewer asks you, “Why is a hospital different than a nuclear power plant or a commercial airline? Why can’t hospitals achieve the same quality levels as high-reliability organizations?” Respond to the questions by explaining the challenges related to ensuring quality and safety standards in hospitals. In addition, explain how hospitals can achieve the same quality levels as high-reliability organizations. (1 page)

3. In your role as a healthcare consultant, administrators and executives often ask you about the differences and similarities between the major accrediting agencies. Many want to know about the DNV surveys and how they compare to The Joint Commission (JC) surveys. Prepare a 1-page document that summarizes the differences and similarities between the JC and DNV surveys. (1 page)

4. Your hospital has recently received deemed status recognition from the Centers for Medicare & Medicaid Services (CMS). At the same time your healthcare analytics department has presented you with the following data

Does the deemed status determination alone guarantee the public that you provide quality healthcare? (1–2 pages)

5. The dean of the Master of Healthcare Administration (MHA) program at your alma mater has asked you to participate in a debate on transparency in the healthcare system. As part of your preparation for the debate, prepare a 2- to 3-page paper in which you:

· Address your definition of the concept of transparency in the healthcare system.

· Explain the primary benefits and drawbacks of transparency in the healthcare system.

· Address your opinion on whether the benefits of transparency in the healthcare system outweigh the drawbacks? Will transparency create more informed healthcare consumers, lead to more questions, or both? Explain your answer.

6. Review the National Patient Safety Goals (NPSG) at 

http://www.jointcommission.org/standards_information/npsgs.aspx

. Then, read the scenarios presented on the Compliance Issues Worksheet provided, and evaluate whether a violation had occurred. Based on your evaluation, complete the worksheet as follows:

· If a compliance issue occurred, identify and classify the issue in the second column of the worksheet.

· If no compliance issue occurred, explain why not (in the second column of the worksheet).

· For each scenario, provide a recommended course of action in the third column of the worksheet.

Examples have been provided in the first two rows of the worksheet.

Presentation Title

Your Name

Program Name or Degree Name, Walden University

COURSE XXX: Title of Course

Instructor Name

Month XX, 202X

Slide Title

Go to the “Home” tab at the top and click the “New Slide” or “Layout” button to access different formatting for your slides.

Choose formatting that presents your information in the most logical way.

Use

consistent, grammatically parallel format

for bulleted lists (for example, on this slide, each element begins with an imperative verb).

You can also consult APA’s suggestions on

formatting lists

.

End bullet points consistently, either with or without a period.

Slide Title

Keep font of text consistent.

Be sure headings are consistent in their spacing, placement, size, etc.

Consider using the slide after the title slide to summarize your presentation’s points (like an

abstract for a paper

).

Slide Title

Your slides can also contain entire paragraphs, like this one does. In both paragraphs and bulleted lists in your presentation, citation rules apply just as they do in papers: when using or referencing another author’s ideas, you must cite that source. When incorporating a citation in a slide, do so just as you would in a traditional paper: According to Jones (2020), presentations are not very different from papers.

According to Smith and Cat (2020), you should make your presentation great, not just good.

Use APA style rules to format any

tables and figures

in your presentation:

Figure 1

Title Reflecting Figure Information

Note. Any needed general notes on figure. From “Utilizing Bar Graphs,” by A. Jones, 2020, Journal of Handy Graphs, 76(2), p. 3 (

https://doi.org/10.123.45/abc

). Reprinted with permission.

Slide Title
Remember to adhere to any assignment guidelines regarding presentation format. This template contains suggestions only.
Keep in mind that there is no such thing as an “APA standard PowerPoint.” Review our presentation tips for more information!
Visit the Academic Skills Center for more tips on how to use PowerPoint or visit Microsoft’s PowerPoint help and learning website.

Slide Title
Always include a reference list at the end of your presentation, just like you would in a paper. Reference list entries take the same format they would in a paper, including a hanging indent. Visit the Common Reference List Examples page for the correct APA format. Here are a few examples:
Jones, P. (2020). This great book. Publisher.
Smith, W., & Cat, D. (2020). How to make a good presentation great. Presentations Quarterly, 45(4), 56-59. https://doi.org/10.123.45/abc

Chart1

Category 1 Category 1 Category 1
Category 2 Category 2 Category 2
Category 3 Category 3 Category 3
Category 4 Category 4 Category 4

Series 1
Series 2
Series 3
4.3
2.4
2
2.5
4.4
2
3.5
1.8
3
4.5
2.8
5

Sheet1

Series 1 Series 2 Series 3
Category 1 4.3 2.4 2
Category 2 2.5 4.4 2
Category 3 3.5 1.8 3
Category 4 4.5 2.8 5
To resize chart data range, drag lower right corner of range.

Compliance Issues Worksheet

Your Name: First and last

Your E-mail Address: Your email here

Instructions

Use this worksheet to complete Prompt 6 of the OM002 Assessment.

Scenario	Compliance Issue	Recommended Course of Action
Example: A patient is discharged without proper instructions for prescribed medication.	Violation of NPSG.03.06.01	Investigate why proper discharge protocols were not utilized.
A recent patient at your hospital contracts Methicillin-resistant Staphylococcus aureus (MRSA). All proper infection-control guidelines were followed.	No violation occurred.	Contact Infection control staff immediately and report the incidence as required.
A phlebotomist does not wash her hands before a blood draw for a post-operative patient.
A patient complains that her hospital identification bracelet is causing a rash. She removes and discards it. The nurse administers medication based on a verbal identification because she recognizes the patient from her previous two shifts.
A patient with no known drug allergies is given a drug. The patient has a reaction to the drug, goes into anaphylactic shock, and dies.
An obese hospital patient requests that an aide help him to the bathroom. The aide requests assistance, but no one is available. The aide escorts the patient alone, and the patient falls.
A nurse in the intensive care unit (ICU) disables an alarm on a machine used to monitor a critically ill patient. When asked about his decision to disable the alarm, he claims the beeping was bothering family members visiting the patient. The patient is treated without incident.
The cleaning staff frequently positions a linen cart so that it blocks access to a fire door in a hospital corridor.
A hospital built in the 1970s does not meet the new fire safety codes.
A blood test indicates an emergency room patient has a serious and highly contagious disease. The blood test results are reported to the attending physician 90 minutes after they are known.
An experienced nurse does not label oral medications for his intensive care unit (ICU) patients because he can identify the medications based on the shape and color of the pills.
A healthy young women checks into the hospital for a minor outpatient procedure. She recognizes the pre-op nurse from her volleyball league. When the nurse asks about what medications she is taking, she withholds that she is taking antidepressants and anti-anxiety medications.
During a pre-procedure verification, an elderly patient with early-stage dementia insists that her left hip will be replaced. Records indicate that her right hip is to be replaced. The operating room (OR) is behind schedule but the surgical team delays the operation to consult with the patient’s family.
A surgeon delegates the marking of the procedure site for an upcoming surgery to a surgical resident.
The operating room (OR) is running almost 2 hours behind schedule. A surgeon has six routine operations. He skips the time-out before the surgical procedures.

©2015 Walden University 3

©2015 Walden University 1

OM002: Organizational Compliance and Regulatory Mandates: Evaluate organizational compliance with regulatory mandates for healthcare

quality and safety.

Assessment Rubric

0
Not Present

1
Needs Improvement

2
Meets Expectations

3
Exceeds Expectations

Sub-Competency 1: Analyze the history of regulatory organizations as it relates to safety and quality in healthcare organizations.

Learning Objective 1.1:
Summarize the history
of the quality
movement in U.S.
healthcare.

Summary of the history
of the quality movement
in US healthcare, in the
slide presentation, is
missing.

Summary of the history of
the quality movement in
U.S. healthcare, in the
slide presentation, is

incomplete, inaccurate, or
vague.

Summary of the history of
the quality movement in
U.S. healthcare, in the
slide presentation, is not
supported by references
to academic resources.

Summary of the history of
the quality movement in
U.S. healthcare, in the
slide presentation, is
accurate.

Summary of the history of
the quality movement in
U.S. healthcare, in the
slide presentation, is
supported by references
to academic resources.

Demonstrates the same
level of achievement as

“2,” plus the following:

Slide presentation
includes the history of
quality management, and
provides specific examples
of quality improvement
initiatives.

Learning Objective 1.2:
Explain the influence of
Deming and
Donabedian in the
healthcare quality-
management
movement.

Explanation of the
influence of Deming and
Donabedian on the
healthcare quality-
management
movement, in the slide
presentation, is missing.

Explanation of the
influence of Deming and
Donabedian on the
healthcare quality-
management movement,
in the slide presentation,
is incomplete, inaccurate,
or vague.

Explanation of the
influence of Deming and
Donabedian on the
healthcare quality-

Explanation of the
influence of Deming and
Donabedian on the
healthcare quality-
management movement,
in the slide presentation,
is in-depth.

Explanation of the
influence of Deming and
Donabedian on the
healthcare quality-
management movement,

Demonstrates the same
level of achievement as
“2,” plus the following:

Slide presentation
includes both text and
graphics, and describes
how organizations can
gain a competitive
advantage.

©2015 Walden University 2

0
Not Present
1
Needs Improvement
2
Meets Expectations
3
Exceeds Expectations

management movement,
in the slide presentation,
is not supported by
references to academic
resources.

in the slide presentation,
is supported by references
to academic resources.

Learning Objective 1.3:
Describe the impact of
the Institute of
Medicine (IOM) reports
on quality management
in the healthcare
system.

Description of the
impact of the IOM
reports on quality
management (policies,
procedures, and
initiative) in the
healthcare system, in the
slide presentation, is
missing.

Description of the impact
of the IOM reports on
quality management
(policies, procedures, and
initiatives) in the
healthcare system, in the
slide presentation, is
incomplete, inaccurate, or
vague.

Description of the impact
of the IOM reports on
quality management
(policies, procedures, and
initiatives) in the
healthcare system, in the
slide presentation, is
clearly described.

Demonstrates the same
level of achievement as
“2,” plus the following:

Slide presentation
describes the cultural shift
in healthcare
organizations driven in
part by the IOM reports.

Learning Objective 1.4:
Describe the role of the
Centers for Medicare &
Medicaid Services (CMS)
in the healthcare
quality-management
movement.

Description of the role of
the CMS in the
healthcare quality-
management
movement, in the slide
presentation, is missing.

Description of the role of
the CMS in the healthcare
quality-management
movement, in the slide
presentation, is
incomplete, inaccurate, or
vague.

Examples are missing,
incomplete, inaccurate, or
vague.

Description of the role of
the CMS in the healthcare
quality-management
movement, in the slide
presentation, is thorough.

Demonstrates the same
level of achievement as
“2,” plus the following:

Slide presentation cites
specific organizational
examples from the media
or other resource in which
CMS had a significant
impact on quality.

Learning Objective 1.5:
Summarize the impact
of The Joint Commission
accreditation on the
quality-improvement
process.

Summary of the impact
of The Joint Commission
accreditation on the
quality-improvement
process, in the slide
presentation, is missing.

Summary of the impact of
The Joint Commission
accreditation on the
quality-improvement
process, in the slide
presentation, is

Summary of the impact of
The Joint Commission
accreditation on the
quality-improvement
process, in the slide
presentation, is concise

Demonstrates the same
level of achievement as
“2,” plus the following:

Slide presentation
includes at least three

©2015 Walden University 3

0
Not Present
1
Needs Improvement
2
Meets Expectations
3
Exceeds Expectations
incomplete, inaccurate, or
vague.

and thorough. examples of how The Joint
Commission accreditation
has impacted a hospital’s
quality-improvement
process.

Sub-Competency 2: Analyze challenges related to ensuring quality and safety standards in hospitals.

Learning Objective 2.1:
Explain the challenges
related to ensuring
quality and safety
standards in hospitals.

Explanation of the
challenges related to
ensuring quality and
safety standards in
hospitals is missing.

Explanation of the
challenges related to
ensuring quality and
safety standards in
hospitals is incomplete,
inaccurate, or vague.

Examples that illustrate
the challenges related to
ensuring safety in
hospitals are missing.

Explanation of the
challenges related to
ensuring quality and
safety standards in
hospitals is clear.

Examples that illustrate
the challenges related to
ensuring safety standards
in hospitals are specific.

Demonstrates the same
level of achievement as
“2,” plus the following:

Response includes an
example of a challenge for
each characteristic of a
high-reliability
organization.

Learning Objective 2.2:
Explain how hospitals
can achieve the same
quality levels as high-
reliability organizations.

Explanation of how
hospitals can achieve the
same quality levels as
high-reliability
organizations is missing.

Explanation of how
hospitals can achieve the
same quality levels as
high-reliability
organizations is
incomplete, inaccurate, or
vague.

Explanation is not
supported by references
to academic resources.

Explanation of how
hospitals can achieve the
same quality levels as
high-reliability
organizations is clear.

Explanation is supported
by references to academic
resources.

Demonstrates the same
level of achievement as
“2,” plus the following:

Response draws on real-
world examples of how
hospitals have overcome
challenges to ensure
quality.

Sub-Competency 3: Identify the foremost accrediting agencies, and explain their roles in assuring or maintaining quality.

Learning Objective 3.1:
Identify the similarities

Identification of the
similarities and

Identification of the
similarities and

Response provides a
thorough summary of at

Demonstrates the same
level of achievement as

©2015 Walden University 4

0
Not Present
1
Needs Improvement
2
Meets Expectations
3
Exceeds Expectations

and differences
between The Joint
Commission and DNV
surveys.

differences between The
Joint Commission and
DNV surveys is missing.

differences between The
Joint Commission and
DNV surveys is
incomplete, inaccurate, or
vague.

Summary is not supported
by reference to academic
resources.

least two similarities and
two differences between
The Joint Commission and
DNV surveys.

Summary is supported by
reference to academic
resources.

“2,” plus the following:

Response provides a
thorough summary of at
least three similarities and
three differences between
The Joint Commission and
DNV surveys.

Learning Objective 3.2:
Explain why
accreditation may or
may not equate to
quality healthcare.

Explanation of why
accreditation may or
may not equate to
quality healthcare is
missing.

Explanation of why
accreditation may or may
not equate to quality
healthcare is incomplete,
inaccurate, or vague.

Explanation is not
supported by references
to academic resources or
data provided in the
question.

Response provides a clear
explanation of the
complexities of the
relationship between
accreditation and quality.

Explanation is supported
by references to academic
resources and the data
provided in the question.

Demonstrates the same
level of achievement as
“2,” plus the following:

Response examines the
question from both the
perspective of a hospital
and the perspective of a
patient with access to
hospital quality metrics.

Sub-Competency 4: Analyze the concept of transparency in the healthcare system.

Learning Objective 4.1:
Define transparency in
the healthcare system.

Definition of
transparency in the

healthcare system is
missing.

Definition of transparency
in the healthcare system is
incomplete, inaccurate, or
vague.

Definition of transparency
in the healthcare system is
clear and concise.

Demonstrates the same
level of achievement as
“2,” plus the following:

Response provides
examples of transparency
in the healthcare system.

Learning Objective 4.2:
Explain the benefits and
drawbacks of

Explanation of the
benefits and drawbacks
of transparency in the

Explanation of the
benefits and drawbacks of
transparency in the

Explanation of the
benefits and drawbacks of
transparency in the
Demonstrates the same
level of achievement as
“2,” plus the following:

©2015 Walden University 5

0
Not Present
1
Needs Improvement
2
Meets Expectations
3
Exceeds Expectations

transparency in the
healthcare system.

healthcare system is
missing.

healthcare system is
incomplete, inaccurate, or
vague.

Personal opinion,
regarding the benefits and
drawbacks of
transparency in the
healthcare system, is
incomplete or vague.

healthcare system is clear.

Personal opinion,
regarding the benefits and
drawbacks of
transparency in the
healthcare system, is
clear.

Response includes at least
three real-world examples
that illustrate the benefits
and drawbacks of
transparency in the
healthcare system.

Sub-Competency 5: Evaluate delivery of care for compliance issues and recommend appropriate courses of action.

Learning Objective 5.1:
Justify the existence or
non-existence of
compliance issues.

Justification of the
existence or non-
existence of compliance
issues is missing.

Justification of the
existence or non-existence
of compliance issues is
incomplete or vague, or
addresses the compliance
issues in fewer than eight
of the scenarios
presented.

Justification is not
supported by references
to academic resources.

Justification of the
existence or non-
existence of compliance
issues accurately
addresses the compliance
issues in at least eight of
the scenarios presented.

Justification for the
existence or non-
existence of compliance
issues within the scenario
is logical.

Justification is supported
by references to academic
resources.

Demonstrates the same
level of achievement as
“2,” plus the following:

Responses accurately and
thoroughly address the
compliance issues in all of
the scenarios presented.

Learning Objective 5.2:
Recommend follow-up
courses of action when
compliance issues occur.

Recommendation of
follow-up courses of
action is missing.

Recommendation of
follow-up courses of
action is not clear or
connected to the

Recommendation for
follow up courses of
action is clear, concise,
and appropriately

Demonstrates the same
level of achievement as
“2,” plus the following:

©2015 Walden University 6

0
Not Present
1
Needs Improvement
2
Meets Expectations
3
Exceeds Expectations

compliance issue. addresses the compliance
issue.

Response demonstrates
the need for a thorough
response from the
organization to address
compliance issues.

PS001: Written Communication: Demonstrate graduate-level writing skills.

Learning Objective
PS 1.1:
Use proper grammar,
spelling, and mechanics.

Multiple major and minor
errors in grammar, spelling,
and/or mechanics are highly
distracting and seriously
impact readability.

Multiple minor errors in
grammar, spelling, and/or
mechanics are distracting
and negatively impact
readability.

Writing reflects
competent use of
standard edited American
English.

Errors in grammar,
spelling, and/or
mechanics do not
negatively impact
readability.

Grammar, spelling, and
mechanics reflect a
high level of accuracy in
standard American
English and enhance
readability.

Learning Objective
PS 1.2:
Organize writing to
enhance clarity.

Writing is poorly organized
and incoherent.
Introductions, transitions,
and conclusions are missing
or inappropriate.

Writing is loosely
organized. Limited use of
introductions, transitions,
and conclusions provides
partial continuity.

Writing is generally well-
organized. Introductions,
transitions, and
conclusions provide
continuity and a logical
progression of ideas.

Writing is consistently
well-organized.
Introductions,
transitions, and
conclusions are used
effectively to enhance
clarity, cohesion, and
flow.

Learning Objective
PS 1.3:
Apply APA style to
written work.

APA conventions are not
applied.

APA conventions for
attribution of sources,
structure, formatting,
etc., are applied
inconsistently.

APA conventions for
attribution of sources,
structure, formatting,
etc., are generally applied
correctly in most
instances. Sources are
generally cited

APA conventions for
attribution of sources,
structure, formatting,
etc., are applied
correctly and
consistently throughout
the paper. Sources are

©2015 Walden University 7

0
Not Present
1
Needs Improvement
2
Meets Expectations
3
Exceeds Expectations

appropriately and
accurately.

consistently cited
appropriately and
accurately.

Learning Objective
PS 1.4:
Use appropriate
vocabulary and tone for
the audience and
purpose.

Vocabulary and tone are
inappropriate and
negatively impact clarity of
concepts to be conveyed.

Vocabulary and tone have
limited relevance to the
audience.

Vocabulary and tone are
generally appropriate for
the audience and support
communication of key
concepts.

Vocabulary and tone
are consistently
tailored to the audience
and effectively and
directly support
communication of key
concepts.

PS003: Technology: Use technology tools effectively.

Learning Objective
PS 3.1:
Use images and layout
of presentations to
effectively communicate
content to a specific
audience.

Images and layout are
inappropriate, hard to
read, and/or impede
audience understanding
of key concepts.

Images or layout provide
limited support for
audience understanding
of key concepts.

Images and layout
generally support
audience understanding
of key concepts.

Images and design
elements are used
purposefully, and they
effectively support
audience engagement and
understanding of key
concepts.

PS005: Critical Thinking and Problem Solving: Use critical-thinking and problem-solving skills to analyze professional issues and inform
best practice.

Learning Objective
PS 5.1:
Analyze assumptions
and fallacies.

Analysis of assumptions
is missing.

Response is weak in
assessing the
reasonableness of
assumptions in a given
argument.

Response does not
adequately identify and
discuss the implications of
fallacies or logical
weaknesses in a given

Response generally
assesses the
reasonableness of
assumptions in a given
argument.

Response identifies and
discusses the implications
of fallacies and/or logical
weaknesses in a given
argument.

Response clearly and
comprehensively assesses
the reasonableness of
assumptions in a given
argument.

Response provides a
detailed and compelling
analysis of implications of
fallacies and logical
weaknesses in a given

©2015 Walden University 8

0
Not Present
1
Needs Improvement
2
Meets Expectations
3
Exceeds Expectations

argument. argument.

Learning Objective
PS 5.2:
Generate reasonable
and appropriate
assumptions.

Assumptions are missing. Response does not
adequately present and
discuss key assumptions in
an original argument.

Response presents and
discusses key assumptions
in an original argument.

Response justifies the
reasonableness and need
for assumptions in an
original argument.

Learning Objective
PS 5.3:
Assess multiple
perspectives and
alternatives.

Assessment of multiple
perspectives is missing.

Response does not
identify nor adequately
consider multiple
perspectives or
alternatives.

Response identifies and
considers multiple
perspectives and
alternatives.

Response justifies
selection of chosen
alternative relative to
others.

Learning Objective
PS 5.4:
Use problem-solving
skills.

Problems and solutions
are not identified.

Response presents
solutions, but they are
ineffective in addressing
the specific problem.

Response presents
solutions that are practical
and work in addressing
the specific problem.

Response presents
compelling supporting
arguments for proposed
solutions.