Sentinel event case study

HT108 January 2017 Case Study: Sentinel Event Policy and Procedure Analysis PLAZA COLLEGE HT108 Health Care Data, Indexes and Registries 3 Credits (2 Didactic, 1 Lab) Case Study: Sentinel Event Policy and Procedure Analysis (NEW) Student Name: ___________________________________ Domain III: Subdomain III.H.1: Competency: Curricular Consideration: Domain V: Subdomain V.A.1: Competency: Curricular Consideration: Domain VI: Subdomain VI.C.2: Competency: Curricular Consideration: Subdomain VI.C.3: Competency: Curricular Consideration: Date: ________ Informatics, Analytics and Data Use Information Integrity and Data Quality Apply policies and procedures to ensure the accuracy and integrity of health data both internal and external to the health system (BL3) Disease management process; Quality assessment & improvement (process, collection tools, data analysis, and reporting techniques). Compliance Regulatory Analyze policies and procedures to ensure organizational compliance with regulations and standards (BL4) Internal and external standards, regulations, and initiatives; Health Insurance Portability and Accountability Act (HIPAA), The Joint Commission, Quality Integrity Organizations (QUIs), Meaningful Use (MU), risk management, & patient safety. Leadership Work Design and Process Improvement Identify cost-saving and efficient means of achieving work processes and goals (BL3) Incident response, medical reconciliation, and sentinel events. Work Design and Process Improvement Utilize data for facility – wide outcomes reporting for quality management and performance improvement (BL3) Data for outcomes reporting; Continuous Quality Improvement (CQI). Objectives: 1. Identify policies and procedures that ensure compliance with data quality and integrity in the process of quality assessment and improvement (III.H.1- BL3) 2. Examine organizational compliance with regulatory standards as it relates to the Joint Commission and patient safety standards (V.A.1- BL4) 3. Analyze different methods of compliance with Quality Improvement Organizations (V.A.1- P) 4. Identify performance improvement tools used in healthcare to monitor patient performance (VI.C.1- BL3) 5. Utilize data for decision making in the process of performance improvement (VI.C.3BL3) 1 HT108 January 2017 Case Study: Sentinel Event Policy and Procedure Analysis TASKS: You are the Quality Assurance/Quality Improvement Director for Plaza Medical Center. As a member of the QA/QI Committee, you have been asked to analyze and recommend improvements to the Sentinel Event Policy, review the Root Cause Analyses and Actions (RCA2) process for its effectiveness, discuss use of the Cause and Effect Diagram (AKA Fishbone diagram) tool which provides leadership a way to explore all the potential factors that may be causing or contributing to a particular problem (effect). In addition, analyze sentinel event data provided by the Joint Commission to identify trend and problem areas to develop strategies or initiatives to address these areas (e.g., education campaign, policy and procedure changes). ▪ Analyze Sentinel Event policy provided and recommend improvements to Policy o Research at least two other sentinel event policies for comparison. o Discuss importance of timely response to a sentinel event. o Review the Root Cause Analyses and