Organization Assessment Worksheet Sample 1

Organization Assessment Worksheet Part 5 of the OM002 Assessment


Before submitting your Assessment, carefully review the rubric. This is the same rubric the assessor will use to evaluate your submission and it provides detailed criteria describing how to achieve or master the Competency. Many students find that understanding the requirements of the Assessment and the rubric criteria help them direct their focus and use their time most productively.


Access the following to complete this Assessment:

Click each of the items below to complete this assessment.

To begin, review:

Note that you first read these resources in OM001.


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.

Part One: History of the Quality-Management Movement in Healthcare

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.

Create a slide presentation to communicate the following information to your audience. (5 – 7 slides)

  • Briefly summarize the history of the quality movement, in general, to set the context for this presentation.
  • Explain the history and influence of Deming and Donabedian (referenced in Chapter 2, 12, and 14 of the Nash text, respectively) 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.

Part Two: Response to Syndicated News Show Interview

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?” Create an audio or video response 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. (2-minute audio or video)

Part Three: Summary of the Differences and Similarities Between the JC and DNV surveys

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. Also, explain why accreditation may or may not equate to quality healthcare (1 page)

Part Four: Transparency in the Health Care System

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 1- to 2-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. Express 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.

Part Five: Organization Assessment Worksheet

Review the National Patient Safety Goals (NPSG) at Then, read the scenarios presented on the Organization Assessment Worksheet provided*, and evaluate whether a violation had occurred. Based on your evaluation, complete the worksheet as follows:

  • If a compliance issue has 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.


Organization Assessment Worksheet

Your Name: First and last

Your E-mail Address: Your email here


Use this worksheet to complete Part 5 of the OM002 Assessment.

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Organization Assessment Worksheet
Organization Assessment Worksheet
ScenarioCompliance Issue If a compliance issue has 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). Recommended Course of Action For each scenario, provide a recommended course of action in the third column of the worksheet.  Example: A patient is discharged without proper instructions for prescribed medication.Violation of NPSG.03.06.01Investigate 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.Violation of NPSG. the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.
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.No violation occurredIdentify patients correctly using at least two ways to identify the patients. For example the patient’s name and date of birth. This ensures that every patient gets the correct medicine and treatment.
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.Violation of NPSG.03.06.01Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.
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.Violation of NPSG.06.01.01Use alarms safely Make improvements to ensure that alarms on medical equipment are heard and responded to on time.
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.Violation of NPSG.06.01.01Use alarms safely Make improvements to ensure that alarms on medical equipment are heard and responded to on time.
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.Violation of NPSG.02.03.01Improve staff communication Get important test results to the right staff person on time.
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.Violation of NPSG.03.04.01Use medicine safely Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up.
A healthy young woman 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.Violation of NPSG. 15.01.01Identify patient safety risk to reduce the risk for suicideDuring 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.No violationImprove staff communication Get important test results to the right staff person on time.
A surgeon delegates the marking of the procedure site for an upcoming surgery to a surgical resident.No violationDelegation to qualified practitioners The surgeon may delegate part of the operation to qualified practitioners including, but not limited to residents, fellows, anesthesiologists, nurses, physician’s assistants, nurse practitioners, surgical assistants or another attending under his or her personal direction. However, the primary attending surgeon’s personal responsibility cannot be delegated. The surgeon must be an active participant throughout the key or critical components of the operation. The overriding goal is the assurance of patient safety.  
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.Violation of UP.01.03.01Prevent Mistakes in surgery. Pause before the surgery to make sure a mistake is not being make.

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