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 (attached), review the Root Cause Analyses and Actions (RCA2) process for its effectiveness, identify missing areas of information using a 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, you must analyze sentinel event data provided by the Joint Commission to identify trends and problem areas to develop strategies or initiatives to address these areas (e.g., education campaign, policy and procedure changes). This must include an assessment and evaluation of how medical record documentation and facility policies on this subject, relate to sentinel events.
Assessments:
Analyze Sentinel Event policy for deficiencies by comparison with two
other sentinel event policies found from research
Examine sentinel event data from the Joint Commission (TJC) website
and provide examples of sentinel events identified by TJC
Evaluate medical record documentation relationship to sentinel events
Assess how facility policies on medical record documentation relate to sentinel events
Recommend revisions to improve the existing policy
Discuss the Root Cause Analyses and Actions (RCA2) process
Define and explain the use of Cause and Effect Diagram tool
Determine the goal and focus of health care facility policies
Create proper APA-formatted reference page with minimum of 5 sources
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