HCA460: Health Care Administration Capstone #4

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

.

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 agency’s purpose

Discuss the agency’s reporting expectations based on the incident

Part 2: Root Cause Analysis: Fishbone Diagram

Create a 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 (Links to an external site.) 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 (Links to an external site.)

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 barriers—for 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)

CMHA-CEI Policies and Procedure Manual
Title:
1.1.14, Sentinel Events
Subject:
BOARD AND ADMINISTRATIVE OPERATIONS
Section:
Administrative
Issued by:
Director of Quality, Customer
Service, and Recipient Rights
Approved by:
Board of Directors
Policy: □
Procedure: X
Page: 1 of 5
Effective Date:
2/8/06
Review Date:
12/9/16
Applies to:
X All CMHA-CEI staff
□ Contract Providers
□ Other:
I.
Purpose: To identify a sentinel event, understand the cause, and take necessary action to reduce
the probability of a future reoccurrence. This procedure is in compliance with the standards
established by Mid-State Health Network (MSHN).
II.
Procedures:
A. Initial actions to be taken when there is suspicion of a sentinel event (refer to Appendix A for
flowchart):
1. Any provider/contract provider will notify their direct supervisor immediately upon
suspicion of a Sentinel Event. An Incident Report will be completed and/or a
Recipient Rights Complaint, as needed.
2. All persons involved in the event will complete a first person account of the event as
soon as possible and within 72 hours of the event.
a. The goal of a first person account is to provide details about the event in a
clear, concise manner, giving as many details as you recall as accurately as
possible. Describe only what you actually witnessed.
b. Send the account directly to the QCSRR Director through secure email or
interoffice mail.
c. The first person account will be used by the QCSRR Director or Compliance
Officer to complete a timeline of events to better inform those conducing a
root causes analysis of the event.
d. All first person accounts will be peer review protected.
e. Only the QCSRR Director or Compliance Officer will review the first person
accounts.
f. All first person accounts will be kept confidential and locked in a filing
cabinet.
3. Peer review protected first person statements will be sent directly to the Quality,
Customer Service, and Recipient Rights (QCSRR) Director as soon as possible and
within 72 hours of the event.
4. The QCSRR Director will determine if the event qualifies as a sentinel event. The
QCSRR Director may involve others in this decision process.
5. If the event is determined to not meet the definition of a sentinel event, the Incident
Report Procedure (3.3.7) and process outlined in that procedure shall be followed or
the Recipient Rights Office will process allegations normally as described in the
Recipient Rights Procedure (3.6.1). The peer review protected first person statements
are not included in the processes outlined in procedures 3.3.7 and 3.6.1.
Procedure #: 1.1.14
Page 2 of 5
Title: Sentinel Events
B. Actions to be taken when it has been determined that a sentinel event occurred:
1. Within 3 business days of the sentinel event, the QCSRR Director will send
notification to the Chief Executive Officer (CEO), the Mid-State Health Network
(MSHN), and the Commission on the Accreditation of Rehabilitation Facilities
(CARF) that a sentinel event has occurred.
C. Actions to be taken if there is a Recipient Rights complaint or allegation:
1. The Recipient Rights office will process allegations normally as described in the
Recipient Rights Procedure, 3.6.1. The peer review protected first person statements
are not included in the process outlined in procedure 3.6.1.
2. Initiating the root cause analysis (RCA) process within 5 business days of the sentinel
event, consultation then occurs within the Review Group (RG) comprised of the
QCSRR Director, Medical Director, Compliance Officer, and Clinical Program
Director.
3. The Recipient Rights Office will work closely with the QCSRR Director to progress
the root cause analysis process as appropriate.
D. Actions to be taken when there is no Recipient Rights complaint or allegation:
1. Initiating the RCA process within 5 business days of the sentinel event, consultation
then occurs within the Review Group (RG) comprised of the QCSRR Director,
Medical Director, Compliance Officer, and Clinical Program Director.
2. The Review Group will identify an employee to review the event and complete
additional fact finding to compose a report that includes a timeline of events and a
list of those who had involvement in the event.
3. The report will be sent to the RG for review.
4. The RG will convene a meeting, with others attending as needed, to progress the
RCA process.
5. The root causes will be determined and action plans to address the root causes will
be implemented.
6. The RCA action plans are approved by the CEO.
7. RCA action plans are monitored by the Compliance Officer with oversight form the
Critical Incident Review Committee (CIRC).
E. Additional Sentinel event review and reporting may be required by accrediting bodies. This
is outside of the scope of this procedure and is the responsibility of the CEI Compliance
Officer or the Director of Quality, Customer Service, and Recipient Rights.
F. CMHA-CEI recognizes that some critical occurrences or incidences, not meeting the
definition of sentinel event, although not technically reportable to any state organization or
accrediting body, warrant a root cause analysis, plan of action, monitoring, and/or evaluation
to reduce the risk of its reoccurrence. The QCSRR Director will determine if incidences not
meeting the standard for sentinel event should have further actions.
III.
Definitions:
A. Root Cause: The most basic reason for failure or inefficiency of a process.
B. Root Cause Analysis: A method of problem solving used to identify the root cause(s) of
faults or inefficiencies.
C. Sentinel Event: An unexpected occurrence to a recipient of services involving death or
serious physical (loss of limb or function) or psychological injury, or the risk thereof.
(Risk thereof includes any process variation that would most likely would result in a
Procedure #: 1.1.14
Page 2 of 5
Title: Sentinel Events
sentinel event if it reoccurred).
D. Recipient of Services:
1. A consumer is considered to an active recipient of services when any of the following
occur:
a.
2.
A face-to-face intake has occurred and the individual was deemed eligible for
ongoing service, or
b. CMHA-CEI has authorized the individual for ongoing service, either through
a face-to-face screening or a telephone screening, or
c. The individual has received a non-crisis, non-screening encounter.
The period during which the consumer is considered to be actively receiving services
shall take place between the following begin date and end date, inclusively:
a.
b.
IV.
Begin Date: Actively receiving services begins when the decision is made to
start providing ongoing non-emergent services. Specifically, the beginning
date shall be the first start date that any of the 3 conditions referenced above
occurs.
End Date: When the consumer is formally discharged from services. The date
the discharge takes effect shall be the end date. This should also be the date
that is supplied to the consumer when the consumer is notified that services
are terminated.
Monitor and Review:
This procedure is reviewed annually by the Director of Quality, Customer Service, and Recipient
Rights. This procedure is monitored by accrediting bodies and regulatory agencies as applicable.
V.
References:
A.
B.
C.
D.
E.
VI.
42 CFR 438.10: Information Requirements
42 CFR 438.400: Appeals and Grievances
MA Contract 6.3: Customer Services
MSHN Procedure 603: Critical Incidents
PIHP Contract Attachment P 7.9.1: Quality Assessment and Performance Improvement
Programs for Specialty Pre-Paid Inpatient Health Plans
Related Policies and Procedures:
CMHA-CEI Policy
CMHA-CEI Procedure
CMHA-CEI Procedure
1.1.14
3.3.7
3.2.08D
Sentinel Events
Incident Reporting
Clinical Peer Review
Procedure #: 1.1.14
Page 2 of 5
VI.
VII.
Title: Sentinel Events
Review Log
Review Date
Reviewed By
Changes (if any)
11/20/07
5/5/11
4/13/14
12/09/16
QI Specialist
Updating to new process, adding flow chart,
updating definitions and references, update
to new format
Attachments:
A. CMHA-CEI Sentinel Event Root Cause Analysis (RCA) Process Flowchart
Attachment A
1.1.14, Sentinel Event Procedure page 4 of 4
CMHA-CEI Peer Review Sentinel Event Process
Updated – July 2016
Potential Sentinel
Event Occurs
Those involved in
the event complete
an incident report
and/or file a Rights
complaint as
appropriate.
If Rights
Complaint
Peer review protected
1st person accounts of
the event are
completed by all
involved and sent to
the QCSRR Director
ASAP, within 72 hours.
The QCSRR
Director
determines* if the
event qualifies as
sentinel.
If Incident
Report
The Rights complaint is
processed normally .
The Incident Report is
processed normally.
Yes
Within 3 business days of the
sentinel event, the QCSRR
Director sends notification to the
CEO, MSHN, and CARF that a
sentinel event has occurred.
Initiating the RCA
process, consultation
occurs between the
Review Group (RG)**
within 5 business days
of the sentinel event.
The RG
identifies a
person to
gather facts.
No
Is the event a
Rights
allegation?
When appropriate
during the Rights
investigation process,
the QCSRR Director
progresses the RCA
process.
The fact finder completes a
review and composes a
report that includes a
timeline of events and a list
of all who had direct or
ancillary involvement in the
sentinel event. The report is
sent to the RG.
The RG reviews the report
and determines who should
attend the RCA meeting. A
meeting is scheduled and
the report is distributed to
attendees.
Yes
The Compliance Officer
creates a follow-up
report and consults with
those involved in the
event.
In close consultation
with the QCSRR
Director, the Rights
department processing
proceeds normally .
Initiating the RCA
process, consultation
occurs between the
Review Group (RG)**
within 5 business days
of the sentinel event.
At the discretion of the
QCSRR Director and
Compliance Officer the
RCA process may be
initiated.
If RCA process
is initiated.
Normal Rights processing does not
include the peer review protected 1st
person accounts.
*Determination of sentinel event
qualification may involve consultation
with the Compliance Officer, Rights
Officer, and others as required.
The RCA meeting
convenes, led by a
designee. The
following is
accomplished:
**The Review Group is comprised of the
QCSRR Director, Medical Director,
Compliance Office, and Clinical Program
Director.
Root Cause(s)
Determined
Action Plan(s)
Developed
The RCA action
plans are approved
by the CEO.
The RCA action plans
are monitored by the
Compliance Officer
with oversight from
the Critical Incident
Review Committee.
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Executive Summary to the CEO
Your Name
University of Arizona Global Campus
HCA 460: Health Care Administration Capstone
Instructor’s Name
Date (spelled out: January X, 20XX)
Hint: Delete all of these green boxes before submitting the paper to your instructor.
To delete the boxes: click on the edge of each box and press delete.
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previously were.
Hint: Ctrl + Click WRITING AN EXECUTIVE SUMMARY for help understanding the purpose of this type of
writing. Note that the sample on this resource is much shorter than your assignment, so take the general
advice but follow this template to create an assignment that meets your instructor’s requirements.
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Executive Summary to the CEO
In this introduction section, begin by first stating your purpose for writing the Executive
Summary to the CEO. Next, preview the main parts of your report so the reader knows what to
expect. End this section with a statement that indicates the thesis or main conclusion of your
paper.
Hint: Ctrl + Click INTRODUCTIONS & CONCLUSIONS for help developing an introduction.
Ctrl + Click WRITING A THESIS for help writing an appropriate thesis statement.
Part 1: The Sentinel Event
Hint: You are asked to use at least 8 credible sources for this paper, 4 of which must come from the University
of Arizona Global Campus Library. In the next 3 sections of your paper, use these resources to help you to
integrate your research into your writing:
Ctrl + Click INTEGRATING RESEARCH
Ctrl + Click QUOTING, PARAPHRASING, & SUMMARIZING
Ctrl + Click CITING WITHIN YOUR PAPER
Scenario Summary and Timeline of the Events
In this section, begin with a summary of the facts related to the sentinel event. Be sure
to describe the event. Also include the staff involved. This information should be the same or
very similar to the scenario you created for the Week 2 Discussion and continued in the Week 3
Discussion.
Next, discuss the timeline events from the initiation of the error through the resolution.
This will vary depending on the sentinel event. Address when and/or where the error occurred,
when it was detected, when it was reported, and to whom it was reported.
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Procedural Errors
Evaluate the procedural errors. This is where you will need to identify the point in time
where the error should have been detected before it occurred. What part of the process or
procedure was missed that contributed to the sentinel event?
Accreditation
Analyze the accreditation agency requirements. Identify which agency would be
involved (e.g., OSHA, ACHA, CMS, CDC, CLIA, TJC, AHCA, state agencies). Define the agency’s
purpose and discuss the agency’s reporting expectations based on the incident.
Part 2: Root Cause Analysis (Fishbone Diagram)
(Note: This is a sample. Do not replicate the contents of this exact diagram. Right click on the
image and select CUT from the list to remove it.)
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For this section, you will create the CQI Tool (Fishbone), complete the tool, copy (or take
a screenshot of) the completed work, and paste the completed diagram here. 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
Hint: Ctrl + Click ACADEMIC VOICE for help using an academic voice in your writing.
In this section, you will create a root cause analysis. In this first paragraph, you will
identify the data elements you would collect to determine the cause and give your rationale for
choosing these data elements. Data elements are the numbers that are used to identify and
track the happenings within the organization. For example, if the sentinel event occurred due
to insufficient staff on duty at the time, the number of staff members on duty is a data element.
Probable Cause
Next, identify the probable cause. This may include process failure, human error,
cultural biases, policy error, systems error, technology failure, or some other issue that may
have contributed to your sentinel event. Include any or all of the following subsections in
completing the probable cause portion of your report.
Human Factors
What human factors were relevant to the outcome?
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Process Errors
What process errors were relevant to the outcome?
Missed Steps
Were there any steps in the process that did not occur as intended?
Equipment Performance
How did the equipment performance affect the outcome?
Other Areas

What are the other areas in the health care organization where this could happen?

Staff Performance
Did staff performance during the event meet the expectations?
Corrective Action Plan
Here, develop a corrective action plan that is geared towards eliminating future events.
Explain the steps of implementing the corrective action plan. Writing at least a paragraph for
each section, discuss the elements below in your response.
Risk Reduction Strategies
Identify the best risk reduction strategies related to your scenario. What will help the
staffing team avoid this kind of event in the future?
Improvement of Processes or Systems
How can the processes or systems be improved to eliminate future events?
Communication Barriers
Discuss the communication breakdown that may have contributed to the sentinel event.
What barriers may have occurred to cause the breakdown in communication? Some of these
6
may include residual intimidation, reluctance to report to a coworker, missing information at
time of transition of care, etc.
Training
What training should be implemented to eliminate future events? This may include
orientation, professional development, cultural competency, skills training, in-service, etc.
Equipment
What equipment should be considered to eliminate future events? This should include
the technology, maintenance, and updates.
Policies and Procedures
What new or revised procedures should be considered to eliminate future events?
Monitoring Process
Describe the monitoring process that will be used to evaluate the success of the
corrective action plan.
Reallocation of Budgetary Resources
Analyze the components that may require the reallocation of budgetary resources. In
this paragraph or series of paragraphs, you will want to consider legal action that may occur
against the organization due to the sentinel event, public relations (reputation leading to
decreased revenue), equipment and supplies, training and education, patient-centered
communication methods (informed consent, procedural education, patient involvement in the
procedure [identify or mark the location of the surgical site]), staffing time for patient
education, and increasing staffing related to workload balance (reallocating staff, role
responsibilities, hiring temporary or permanent staff). Include your rationale for each action
7
you recommend. Additionally, explain how each part will benefit the organization (make a
connection between the recommendations and how it will help in avoiding the sentinel event in
the future).
Conclusion
Restate the conclusion or overall recommendation of the report. Recap the main points.
Hint: Ctrl + Click INTRODUCTIONS & CONCLUSIONS for help developing a conclusion.
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References
Include at least eight scholarly or credible sources in your assignment. Use APA Style to format your
sources on the References page. You must include in-text citations throughout your paper to show your
reader what information you used from outside sources.
APA academic journal reference entry
Author, A. A., Author, B. B., & Author, C. C. (Year). Article title. Journal Title, volume #(issue #), page
range. http://doi.org/xxx.xxx.xxx.xxx
APA webpage (with a person as author) reference entry
Author, A. A. (Year, Month Day). Webpage title. Website Title. http://(URL)
APA webpage (with corporate/government author) reference entry
Title of Organization. (Year, Month Day). Webpage title. Website Title. http://(URL)
APA etextbook reference entry
Author, A. A. (Year Published). Title of book: Subtitle of book (edition, if other than the first). Publisher
Name. https://doi.org/xxx.xxx.xxx (ebook’s DOI, or https://(URL) if not contained within a
database and DOI is unavailable)
APA online video entry
Author, A. [Screen name, if different]. (Year, Month Day). Title of video [Video]. Platform Name.
https://(URL)
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Right-click APA: Formatting Your References List for further help.
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