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Sentinel Event Action Plan – OIG Guidelines

Action Plan

A detailed action plan that identifies risk reduction strategies must be stated for each root cause identified. If a risk reduction is not warranted for the identified cause, an explanation is required. A risk reduction plan should also be developed for any other issues identified as opportunities for improvement that were identified in the analysis but may not be considered root causes. The following components must be addressed: risk reduction strategy, person responsible for implementation, date of implementation, and measures of effectiveness. The measures of effectiveness are the same as a performance indicator. They should include anticipated outcome and measure whether or not the action taken was effective.

Root Cause(s)/Opportunity for Improvement(s):

Highlight and summarize the root cause(s)/ Opportunity for Improvement(s) Issue identified during the root cause analysis.

Risk Reduction Strategy:

Outline in detail the action plan steps taken to promote change. Be specific. If you change a policy and procedure, summarize the change that you are making. Outline how you are going to implement the policy and procedure (e.g., educate staff, perform post test for staff, etc.).

Person(s) Responsible for Implementation:

Identify by title the individual responsible for implementing the particular risk reduction step.

Target date of implementation:

Outline the anticipated date of completion of each identified step. Outline the actual completion date for steps already completed.

Location of implementation:

Improvements to reduce risk should ultimately be implemented in all areas where applicable, not just where the event occurred. Identify where the improvements will be implemented.

Completion date:

Date the corrective action was implemented.

Measures of Effectiveness/Performance Indicators:

Outline the plan for measuring the effectiveness of each risk reduction strategy.

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Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state law.

It is not to be distributed outside the quality assurance, performance improvement, peer review process.

Indicators must be objective, measurable, and quantifiable. (Use outcome based measurements whenever possible)

Measures of effectiveness need to have the data collection methodology outlined.

Using a random sample? Define random.

Give sample size and method of collecting.

Are you determining effectiveness by observation? Pre-test/post-test? Pilot test? Audit tool? Explain.

Set a target range that reflects the desired range of performance for each indicator

If measurement is not identified, reason must be documented. (*)

All risk reduction measurement strategies will be evaluated and reported to Senior Leadership within 3 months of completed and approved RCA and updated quarterly.

Root Cause(s)/Opportunity for Improvement(s):

Risk Reduction Strategies Target Implementation

Date

Responsible Party

Location of Implementation

Completion Date

Measures of Effectiveness

Measure:

Measure:

Measure:

Measure:

Measure:

Measure:

Measure:

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Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state law.

It is not to be distributed outside the quality assurance, performance improvement, peer review process.

Cite any books or journal articles that were considered in developing this action plan: