Prior to beginning work on this assignment,
Read the Writing Center Writing an Executive Summarywebpage.
Read the CMHA-CEI Policies and Procedures Manual: 1.1.13, Sentinel Events Download CMHA-CEI Policies and Procedures Manual: 1.1.13, Sentinel Events.
Read the Continuous Quality Improvement (CQI) Strategies to Optimize Your Practice resource.
Read the Medical Errors Nursing CE Course webpage.
Read the QUERI Quality Enhancement Research Initiative: QUERI Implementation Roadmap Download QUERI Quality Enhancement Research Initiative: QUERI Implementation Roadmapresource.
Read the Sentinel Events CY2018: Annual Report to the Maine State Legislature
Read the Six Steps for Successful Incident Investigation webpage.
Read the Tools: Cause and Effect Diagram website.
Watch the following videos that describe the details included in a Fishbone Diagram
Whiteboard: Cause and Effect Diagram by Institute of Healthcare Improvement
Quality (Part 2: Ishikawa Diagram) by Infinity MFG
Read the Using Quality Improvement Methods for Evaluating Health Care article.
For this written assignment, you will prepare an executive summary for the CEO using the same sentinel event addressed earlier in the course. This report will be prepared for the CEO of the organization where the sentinel event occurred. The CEO is then required to provide details from the executive summary to the Board of Trustees and other stakeholders in the organization to identify the next steps of managing the sentinel event.
Managing a sentinel event usually consists of the following steps: immediate action, planning the investigation, data collection, data analysis, corrective action plan, and reporting to accreditation agencies. For this assignment, first, review details from the Week 2 and Week 3 discussions, including responses from peers, as well as instructor gradebook feedback. Then, you will focus on the parts below to develop a cohesive plan to address the sentinel event. Address the following in the Executive Summary to CEO template Download Executive Summary to CEO template.
Part 1: The Sentinel Event
Summarize the facts related to the sentinel event:
Description of the event
Staff involved
Discuss the timeline events from initiation of the error through the resolution (will vary depending upon the sentinel event):
When and/or where did the error occur?
When was it detected?
When was it reported and to whom?
Evaluate procedural errors:
Identify the point in time when the error should have been detected before it occurred.
What part of the process or procedure was missed that contributed to the sentinel event?
Analyze accreditation agency (e.g., OSHA, ACHA, CMS, CDC, CLIA, TJC, AHCA, state agencies) requirements:
Identify which agency(s) would be involved
Define the agencys purpose
Discuss the agencys reporting expectations based on the incident
Part 2: Root Cause Analysis: Fishbone Diagram
Create a fishbone diagram Download fishbone diagram. You will be responsible for creating the CQI Tool (fishbone), completing the tool, copying or taking a screenshot of the completed work, and pasting the completed fishbone diagram into the final document.
If you are unfamiliar with the fishbone, please refer to the Using Quality Improvement Methods for Evaluating Health Care article by Siriwardena (2009).
In addition, as a learning resource, the CQI tool listed below is hyperlinked to the Institute for Health Care Improvement website, which discusses and illustrates an example of the Fishbone. Tools: Cause and Effect Diagram
Part 3: Root Cause Analysis Report
Create a root cause analysis.
Identify the data you would collect to determine the cause.
Give your rationale for choosing the data.
Identify the probable cause, which may include a process failure, human error, cultural biases, policy error, systems error, technology failure, etc., that may have contributed to the sentinel event. Consider the following as applicable to your chosen event as you complete this segment:
What human factors were relevant to the outcome?
What process errors were relevant to the outcome?
Were there any steps in the process that did not occur as intended?
How did the equipment performance affect the outcome?
What are the other areas in the health care organization where this could happen?
Did staff performance during the event meet the expectations?
Develop a corrective action plan that is geared towards eliminating future events.
Explain the steps of implementing the corrective action plan. Consider the following in developing your response to this component:
Identify risk reduction strategies
Improvement of processes or systems
Communication barriersfor example, discuss the communication breakdown that might have contributed to the sentinel event, or what barriers may have occurred to cause the breakdown in communication (e.g., residual intimidation, reluctance to report a coworker, missing information at time of transition of care, etc.).
Training (e.g., orientation, professional development, cultural competency, skills training, in-service)
Equipment (e.g., technology, maintenance, and updates)
Policies and procedures (e.g., new or revised)
Describe the monitoring process that will be used to evaluate the success of the corrective action plan.
Analyze the components that may require the reallocation of budgetary resources. Consider the following as applicable to your sentinel event:
Legal action
Public relations (reputation leading to decreased revenue)
Equipment and supplies
Training and education
Patient-centered communication methods (e.g., informed consent, procedural education, patient involvement [identify or mark the location of the surgical site])
Staffing (e.g., reallocating staff, role responsibilities, hiring temporary or permanent staff)
