QAPI Program Utilization_Manual

The subcommittee will formulate a “work plan” with established objectives and target dates and will submit the plan to the Performance Improvement Committee and Administration for perusal and approval. Event Analysis Subcommittee meetings will include discussion about and documentation of the following: Sequencing of the events that resulted in the sentinel event Brainstorming all actual or potential contributing factors Concrete clarification of the root cause(s) the sentinel event Consideration of relevant pertinent literature Organization and analysis of causative factors, listing the factors in identified cause/effect priority order using data collected from sources such as surveys, samplings, checklists, etc. Identification of those systems or processes related to the causative factors, determining the relation of each cause to the system or process using such methodologies as flow charts, fishbone diagrams and/or trend (run) charts Identification and recommendation of implementation of actions that will promote prevention of further event recurrence. The Event Analysis Subcommittee shall formulate and submit the action plan to the Performance Improvement Committee and Administration for perusal and approval. The action plan contains the following elements: Methodologies to improve processes and time frames for completion Identification of the person(s) responsible for implementation of the action plan, along with progress reporting dates The methodologies by which the effectiveness of the action plan shall be measured, assessed and evaluated through data collection, aggregation and analysis The action plan is monitored and evaluated for a time period designated by the Performance Improvement Committee and Agency leadership to ensure that performance improvement is sustained. The root cause analysis minutes, reports and the corrective plan of action are submitted to the Performance Improvement Committee and Agency Administration within five (5) business days of the initial report of the occurrence and distributed to appropriate committees and individuals as necessary and appropriate. 83