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
    • Research at least two other sentinel event policies for comparison.
    • Discuss importance of timely response to a sentinel event.
    • Review the Root Cause Analyses and Actions (RCA2) process.
    • Discuss use of Cause and Effect Diagram (AKA Fishbone diagram) tool.
    • Locate and analyze sentinel event data published by Joint Commission and recommend quality improvement activities.
  • Using Microsoft Word, compose a detailed two page essay double spaced using Times New Roman, size 12 font.
    • Provide a works cited page with at least five sources.
  • Analysis of Sentinel Event policy _______/20
    Analysis of sentinel event data _______/15
    Recommend ways to improve the existing policy _______/15
    Discuss the Root Cause Analyses and Actions (RCA2) process _______/15
    Discuss use of Cause and Effect Diagram tool _______/15
    Recognize the goal and focus of health care institutions policy _______/10
    Give examples of Sentinel events identified by the TJC ________/5
    Correct spelling, punctuation, grammar and formatting ________/5

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