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Herzing University Herzing the Standards Cited Action Plan

Herzing University Herzing the Standards Cited Action Plan

Question Description

Preparing a plan for action for improvement is as important as executing the plan. In this assessment, review hospital survey data and prepare a plan of action to positively move forward.

Evaluation Title: Action Plan

Assume the role of the manager of the QI Department in a hospital. Recently, the Healthcare Facilities Accreditation Program (HFAP) conducted a survey on the hospital. The survey results have been made available.


  • Open and review the pdf of survey results entitled, “Mastering the Standards for Survey Success: The 2018 HFAP Quality Review (Links to an external site.).”
    • Open and review the pdf of survey results entitled, “HFAP Top Cited Standard level Deficiencies of 2012.”
  • Identify three standards that were cited.
  • Create an action plan for each citation. The action plan should include:
    • The standard with expectations
    • A timeline for implementation
    • Details as to how the hospital can reduce this issue so when the organization comes through for a recheck in 3 months, the citation will be eliminated.
  • Complete additional research on this topic, utilizing a minimum of 4 sources support ideas presented.


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