DEVELOPING AND IMPLEMENTING A CORRECTIVE ACTION PLAN Linda Ohler, MSN, RN, CCTC, FAAN Quality and Regulatory Manager George Washington University Transplant Institute And Editor, Progress in Transplantation 1
Objectives 1. Describe steps for effective corrective action planning 2. Discuss methods for implementing the corrective action plan 3. Evaluate effectiveness of the corrective action plan through tracking and analyzing data 4. Critique a real life CAP Where do you want to go? Alice: I was wondering if you could help me find my way? Cheshire Cat: It depends on where you want to go. Alice: Oh, it really doesn t matter as long as. CC: Well, if it doesn t matter then any road will get you there. 2
What is a Corrective Action Plan? Step by step plan of action Focuses on resolving an error or deficiency Identifies options/actions to correct errors Allows us to select the most cost effective and efficient actions Identifies actions to improve processes and prevent recurrences Needs measurable goals to provide direction Why is a formal process needed for corrective actions? Ensures a process is implemented to improve: A regulatory deficiency An identified patient safety issue An analysis of an adverse event (root cause) Outcomes Processes Identifies a team with leadership to implement and oversee improvements Establishes time lines for meeting goals 3
Why a Corrective Action Plan? Promotes Program Improvement Corrective Actions are Implemented and Monitored When is a corrective action plan necessary? Direction is needed New process or event is being planned Self identified problem needs to be corrected Staffing turnover Not meeting performance measures Regulatory deficiency CMS or UNOS identifies a problem with your center meeting standards 4
DESCRIBE THE STEPS IN DEVELOPING A CORRECTIVE ACTION PLAN What are the steps to developing a corrective action plan? 1. State the problem 2. Identify those responsible 3. Brainstorming 4. Create measurable goals (SMART) 5. Identify potential barriers 6. Assign responsibilities 7. Identify and implement training that may be needed 8. Track/Monitor the corrective action progress 9. Analyze data 10. Ensure actions are cost effective 5
DISCUSS METHODS FOR IMPLEMENTING THE CORRECTIVE ACTION PLAN Why not a PI Project? Why dive into a CAP? Example of error found in an Audit Problem identified Identify UNOS standard Policy 3.3 A 6
And I had signed about 10! Identify the problem Patients were having blood drawn twice Phlebotomist were filling out labels by hand Patients were registered but we were in a separate building with no ability to print labels. 7
IDENTIFY THOSE RESPONSIBLE Director of Operations Director of Lab Director for Registration Transplant IT Transplant QAPI and Regulations Investigate! 8
Identify potential barriers to meeting goals Barriers Director of Registration just tells us it cannot be done Lack of ability to register patients on site No ability to print labels Not able to enter orders from off site clinics Ambulatory and Inpatient systems are not compatible Geography Budget does not include hiring a phlebotomist Brainstorming 9
Real life CAP IT software incompatibilities GWU Hospital Medical Faculty Associates 10
Medical Faculty Associates Assign Responsibilities Leader Team members Responsibilities Writing the Plan Implementing Tracking Analyzing Reporting Linda Linda, Sherri, Lab Linda Linda, IT, Lab Linda, Sherri, LAB, IT, Registration 11
Education of stakeholders ABO being drawn twice but reported as one draw. Regulation: Intervention: Called a meeting of Stakeholders: Lab Registration IT from MFA IT from GWU transplant institute 12
Monitoring the Plan Intervention: Hired our LAB phlebotomist 13
Audits Audits were monthly Audits are with each patient registration IT has figured out how to do this GWU Hospital Medical Faculty Associates Not a factor 14
Registration will begin in our building Analyze data/outcomes ABO September data 100% Will monitor for one year Phlebotomist 2 months Doing well Registration IT will set up September 25 Registration begins in our building on September 28 15
WHAT TEMPLATE/TOOL IS MOST USEFUL FOR CORRECTIVE ACTION PLANNING? Prepared Templates Your hospital s template UNOS/CMS 16
UNOS Transplant Pro CAP 17
A3 Congrats! You have a plan! 18
Any Questions 19