Step-by-Step Guide: KCM1 Task 1 — Accreditation Audit (AFT2)

KCM1 Task 1 — Accreditation Audit (AFT2)

Introduction

In this task, you are preparing for an accreditation audit. There are many variables that must be considered to ensure compliance with Joint Commission standards. In order for the audit to be successful, you must be aware of the accrediting agency’s guidelines.

Requirements

Your submission must represent your original work and understanding of the course material. Most performance assessment submissions are automatically scanned through the WGU similarity checker. Students are strongly encouraged to wait for the similarity report to generate after uploading their work and then review it to ensure Academic Authenticity guidelines are met before submitting the file for evaluation. See Understanding Similarity Reports for more information.

Grammarly Note:

Professional Communication will be automatically assessed through Grammarly for Education in most performance assessments before a student submits work for evaluation. Students are strongly encouraged to review the Grammarly for Education feedback prior to submitting work for evaluation, as the overall submission will not pass without this aspect passing. See Use Grammarly for Education Effectively for more information.

Microsoft Files Note:

Write your paper in Microsoft Word (.doc or .docx) unless another Microsoft product, or pdf, is specified in the task directions. Tasks may notbe submitted as cloud links, such as links to Google Docs, Google Slides, OneDrive, etc. All supporting documentation, such as screenshots and proof of experience, should be collected in a pdf file and submitted separately from the main file. For more information, please see Computer System and Technology Requirements.

You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.

A. Create an executive summary for senior leadership outlining the current compliance status of the organization based on the attached Accreditation Audit Case Study – Task 1 Artifacts for one priority focus area of the Joint Commission standards (e.g., infection control, communication, medical management, information management).

1. 1. Develop a corrective action plan that would ensure compliance with the Joint Commission standards for the identified
   2. Justify why the review area that you selected is important to the

B. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summrized.

C. Demonstrate professional communication in the content and presentation of your submission

Step-by-Step Guide: KCM1 Task 1 — Accreditation Audit (AFT2)

Course Context & What This Task Is

This is a healthcare administration/compliance task for WGU’s AFT2 course. You are playing the role of a healthcare manager preparing for a Joint Commission accreditation audit. Your job is to:

1. Review the case study artifacts provided
2. Write an executive summary on the organization’s current compliance status
3. Develop a corrective action plan (CAP)
4. Justify why the area you selected matters to the hospital

The submission is a Word document (.docx) — no template is provided, so you write this as a structured professional report.

Before You Write Anything

Step 1 — Download and Study the Supporting Documents

There are two zip files attached to the task:

• Accreditation Audit Case Study General Artifacts.zip — background on the hospital
• Accreditation Audit Case Study Task 1 Artifacts 2024.zip — the audit findings you will analyze

Open both and read carefully. Look for:

• The hospital’s name, size, and type
• Any documented deficiencies, near-misses, or compliance gaps
• Data tables, audit checklists, incident logs, or survey results

Step 2 — Select ONE Priority Focus Area

The task gives you these examples to choose from:

How to choose: Pick the area that has the most deficiency evidence in the case study artifacts. The more data you have, the stronger your paper. Infection Control and Medication Management are typically the richest in WGU case studies.

Document Structure

Your paper should have these clearly labeled sections:

1. Executive Summary (Section A)
2. Corrective Action Plan (Section A1)
3. Justification (Section A2)
4. References (Section B)

Recommended length: 5–8 pages, double-spaced, Times New Roman 12pt, APA 7 format.

Section A — Executive Summary (Rubric: Sufficient detail on compliance status)

What the rubric requires:

A detailed executive summary of the organization’s current compliance status for your chosen Joint Commission focus area, based on the case study.

How to write it:

Opening paragraph — Set the context:

Identify the hospital by name (from the case study), its size, patient population, and the specific Joint Commission standard area being reviewed. State the purpose of the executive summary.

Compliance Status Body — This is the core of Section A. Cover ALL of the following:

1. Current performance data — What do the artifacts show? Pull specific numbers, percentages, or incident counts from the case study. For example:
   • “Hand hygiene compliance rates were recorded at 67%, below the Joint Commission benchmark of 90%.”
   • “Three medication labeling errors were documented in the past quarter.”
2. Specific Joint Commission standards being evaluated — Name the actual TJC standard(s). Examples by focus area:

   Focus Area	Relevant TJC Standard
   Infection Control	IC.02.01.01 — Reduce infection risk
   Medication Management	MM.04.01.01 — Safe medication storage
   Communication	PC.02.02.01 — Patient care handoffs
   Information Management	IM.02.02.01 — Documentation accuracy

3. Gaps identified — What specific areas are out of compliance based on the artifacts?
4. Risk level — Characterize the severity (high, medium, low risk to patient safety and accreditation status)

Closing paragraph — Summarize the overall compliance picture and transition into the corrective action plan.

Competency tip:

“Sufficient detail” means you must reference specific findings from the case study artifacts — not just general statements. Evaluators will check that your summary is grounded in the provided data, not invented.

Section A1 — Corrective Action Plan (Rubric: Sufficient detail, ensures compliance)

What the rubric requires:

A detailed corrective action plan (CAP) that would bring the organization into compliance with the identified Joint Commission standards.

How to structure the CAP:

A strong CAP has five components for each action item:

Sample CAP Table Format:

Write prose explanation around the table. Don’t just submit the table alone — explain the rationale for each action and how it directly addresses the Joint Commission standard.

What makes this “sufficient detail”:

• Each action is specific and measurable (not vague like “improve hand hygiene”)
• Each action is directly tied to a TJC standard
• Timelines are realistic and stated
• A monitoring/follow-up mechanism is included

Section A2 — Justification (Rubric: Logical justification with sufficient support)

What the rubric requires:

Explain why the focus area you selected is important to the hospital — not just why it matters in general, but why it is specifically significant to this organization.

How to write it:

Structure your justification around three angles:

1. Patient Safety Impact Explain how deficiencies in this area directly endanger patients. Use data from the case study or peer-reviewed literature to support the claim. Example for infection control:

“Healthcare-associated infections (HAIs) affect approximately 1 in 31 hospitalized patients on any given day (CDC, 2024). Given the organization’s current 67% hand hygiene compliance rate, the risk of preventable HAIs is substantially elevated, placing vulnerable patients at direct risk.”

2. Regulatory and Accreditation Consequences Explain what the hospital stands to lose if this area is not corrected:

• Risk of Joint Commission accreditation denial or probation
• Potential CMS Conditions of Participation violations (loss of Medicare/Medicaid funding)
• State licensing implications
• Public reporting and reputational damage (e.g., Hospital Compare scores)

3. Financial and Operational Impact Tie the deficiency to real organizational costs:

• HAI-related costs average $28,400 per infection (for CLABSI, for example)
• CMS does not reimburse for certain preventable conditions under the Hospital-Acquired Condition Reduction Program
• Staff time lost to outbreak management, litigation exposure, increased length of stay

Competency tip: “Sufficient support” means backing your justification with cited evidence — at least 2–3 peer-reviewed sources or authoritative organizational sources (CDC, TJC, AHRQ, CMS). Don’t rely solely on the case study for this section.

Section B — Sources (Rubric: Accurate APA 7 in-text citations + reference list)

Requirements:

• Every factual claim, statistic, or standard you reference must have an in-text citation
• All citations must appear in a References list at the end
• Follow APA 7th edition format exactly

Minimum sources to include:

APA 7 in-text format:

• One author: (Smith, 2023)
• Two authors: (Smith & Jones, 2023)
• Organization: (CDC, 2024)
• Direct quote: (Smith, 2023, p. 45)

Section C — Professional Communication

Pre-submission checklist:

• Run through Grammarly for Education — this is required and will block passage if not done
• No sentence fragments or run-on sentences
• Consistent formal academic tone (no contractions, no casual phrasing)
• All sections clearly labeled with headings
• APA 7 format throughout (title page, running head if required, double-spaced, 12pt Times New Roman)
• File saved as .docx
• File name uses only allowed characters (letters, numbers, spaces, ! - _ . * ' ( ))

Full Rubric-to-Section Mapping

Recommended Writing Order

1. Read the artifacts first — don’t write a single word until you know what deficiencies exist in the case study
2. Pick your focus area based on available evidence
3. Write the CAP first (Section A1) — this is the most concrete section and anchors everything else
4. Write the Executive Summary (Section A) — summarize the deficiencies your CAP addresses
5. Write the Justification (Section A2) — argue why those deficiencies matter
6. Add citations and References (Section B)
7. Run Grammarly and polish (Section C)

Common Reasons Students Get “Approaching Competence”