Developing Strong Action Plans Diane Rydrych Assistant Director, Division of Health Policy, Minnesota Department of Health Betsy Jeppesen Vice President, Program Integrity Stratis Health Sue Ann Guildermann Director of Education Empira Linda Shell Corporate Director, Education Volunteers of America
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Developing Strong Action Plans Diane Rydrych Assistant Director, Division of Health Policy, Minnesota Department of Health Betsy Jeppesen Vice President,
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Developing Strong Action Plans
Diane RydrychAssistant Director, Division of HealthPolicy, Minnesota Department of Health
Betsy JeppesenVice President, Program Integrity Stratis Health
Sue Ann GuildermannDirector of EducationEmpira
Linda ShellCorporate Director, EducationVolunteers of America
Now that you know the root causes and contributing factors that led to the event or serious accident, what actions will you put into place to reduce the chance of it reoccurring?
Corrective actions often include:
• Education and training• Telling staff to “be more careful”• If we stop at these actions, will we prevent a
reoccurrence?
Hierarchy of actions• National Center for Patient Safety’s
“Hierarchy of Actions” classifies corrective actions as:– Weaker: actions that depend on staff to remember their
training or remember what is written in the policy – Intermediate: actions are somewhat dependent on staff
remembering to do the right thing, but they provide tools to help staff to remember or to promote clear communication
– Strong: actions that do not depend on staff to remember to do the right thing; the action may not totally eliminate the vulnerability but provide very strong controls
Dept of Veterans Affairs National Center for Patient Safety, http://www.patientsafety.gov/CogAids/RCA/index.html
To be most effective, action plans need to move to stronger actions than education or reminders alone
Hierarchy of actions: weaker • Double checks (risk for human error)• Posters or signs on the new requirement• New procedure, policy, memo• Training alone• Additional study/analysis
Dept of Veterans Affairs National Center for Patient Safety, http://www.patientsafety.gov/CogAids/RCA/index.html