Developing Strong Action Plans

Diane RydrychAssistant Director, Division of HealthPolicy, Minnesota Department of Health

Betsy JeppesenVice President, Program Integrity Stratis Health

Sue Ann GuildermannDirector of EducationEmpira

Linda ShellCorporate Director, EducationVolunteers of America

Now that you know the root causes and contributing factors that led to the event or serious accident, what actions will you put into place to reduce the chance of it reoccurring?

Corrective actions often include:

• Education and training• Telling staff to “be more careful”• If we stop at these actions, will we prevent a

reoccurrence?

Hierarchy of actions• National Center for Patient Safety’s

“Hierarchy of Actions” classifies corrective actions as:– Weaker: actions that depend on staff to remember their

training or remember what is written in the policy – Intermediate: actions are somewhat dependent on staff

remembering to do the right thing, but they provide tools to help staff to remember or to promote clear communication

– Strong: actions that do not depend on staff to remember to do the right thing; the action may not totally eliminate the vulnerability but provide very strong controls

Dept of Veterans Affairs National Center for Patient Safety, http://www.patientsafety.gov/CogAids/RCA/index.html

To be most effective, action plans need to move to stronger actions than education or reminders alone

Hierarchy of actions: weaker • Double checks (risk for human error)• Posters or signs on the new requirement• New procedure, policy, memo• Training alone• Additional study/analysis

Dept of Veterans Affairs National Center for Patient Safety, http://www.patientsafety.gov/CogAids/RCA/index.html

Hierarchy of actions: intermediate• Redundancy—everyone entering room looks for “x”• Eliminate/reduce distractions• Checklists, cognitive aids• Eliminate look-alikes and sound-a-likes• Read back—verbal orders• Software enhancements/modifications• Increase staffing; decrease workload• Enhanced documentation/communication

Dept of Veterans Affairs National Center for Patient Safety, http://www.patientsafety.gov/CogAids/RCA/index.html

Hierarchy of actions: stronger• Physical plant changes—e.g., moving a grab

bar • Simplify the process—remove unnecessary

steps or steps that no longer make sense• Standardize equipment or process to reduce

variation • Conduct usability testing before purchasing

new devices—will it really do what you need?

Hierarchy of actions: stronger

• Engineering controls (forcing functions): – Edits on electronic medical record that won’t let

you exit until a field is filled– IV tubing that will not allow you to connect certain

types of piggy backs

• Tangible involvement/action by leadership in support of resident and staff safety– Leadership checks in with staff during rounds on

how a new process is going, and follows up if issues are identified

Action plans

Are action plans:• Linked directly to the root cause(s) and

contributing factors—will the actions keep event from happening again?

• Easily understood and can be implemented —practical and achievable?

• Developed whenever possible with involvement of those closest to the process?

Action plans

Does the action plan:• Identify someone who will be responsible for

implementation (not necessarily the one who will do all the steps, but who will check in with the team to assure it is accomplished)?

• Have an identified target date for implementation?

• Include a measurement plan to determine if the change is having the intended effect?

Action plans• Important to communicate plan to leadership

and staff—sharing at staff meetings is not enough (a weak action)

• Regular interaction with staff carrying out plan is key to evaluating if it is working and to make sure the fix sticks

Follow through• Appreciate and recognize staff efforts• Listen to staff when they share impact of the

change• Share data that shows impact with staff

(residents and families if appropriate)• Be ready to consider additional analysis or

action if the plan is not having the intended effect

Questions?Sue Ann Guildermann

Director of Education

Empira

952-259-4477

sguilder@empira.org

www.empira.org

Diane Rydrych

Assistant Director

Division of Health Policy

Minnesota Department of Health

651-201-3564

Diane.rydrych@state.mn.us

www.health.state.mn.us/patientsafety

Betsy Jeppesen

Vice President, Program Integrity

Stratis Health

952-853-8510 or 877-787-2847

bjeppesen@stratishealth.org

www.stratishealth.org

Linda Shell

Corporate Director,

Education and Learning

Volunteers of America

651-503-8885

lshell@voa.org

Protecting, maintaining, and improving the health of all Minnesotans. 

Stratis Health is a nonprofit organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted

expert in facilitating improvement for people and communities.