Where are you at risk?
No images? Click here
Together With
The Best Value for 40 CEUs- 20% off
Take advantage of online, self-paced, affordable NAB-approved CEUs. Purchase a bundle or pick the exact number of credits you need. No recurring payments. no surprise charges next year. Use discount code "nhastandup" and visit our site here.
Good afternoon. Welcome to week 3 of our journey to create a culture of safety and awareness with regard to elopement risks.
If you missed week 1, check it out here.
If you missed week 2, review it here.
Elevate your Leadership
Week 3
During week 1, we identified our process gaps.
Last week, week 2, we completed drills to identify our responsiveness and operational gaps. You completed real-time education to address areas of opportunity.
Week 3 is all about fixing processes and preparing for education.
Your tasks for the week are as follows.
Pull together your leadership team to discuss and develop two separate deliverables.
You will delegate the first deliverable to them. Referring back to week 1's exercise, where are our process gaps?
Deliverable #1:
Have each department develop a QAPI plan in the form of a plan of correction (POC) to address how they will get back to and maintain compliance with your policies and procedures. QAPI plans are due this coming Wednesday, and your team should begin reporting on their specific plans at your stand-up meeting on Friday and each Friday moving forward.
For example, let's say your policy calls for exterior door alarms to be checked by maintenance every week, and that has not occurred. The QAPI plan could read like this.
How the facility will correct the deficiency for those affected: Immediate action will be taken to ensure that all exit door alarms are checked for proper functioning as per the weekly schedule. The maintenance team will be instructed to perform the overdue checks immediately and address any issues found.
What systematic change will be put in place to prevent the issue/deficiency from recurring: The facility will re-educate the maintenance team on the importance of adhering to the policy for checking exit door alarms. The Director of Maintenance will be responsible for carrying out this education and ensuring compliance. The NHA will educate the maintenance director.
How will you measure the impact or success of your systematic change: The facility will implement a system of accountability by requiring the maintenance team to submit weekly reports confirming the completion of alarm checks. The NHA will audit these reports weekly for one month and then monthly for two additional months to ensure compliance. Audit results will be forwarded to the Quality Assurance and Process Improvement (QAPI) committee for review and recommendation.
The date by which the facility will achieve compliance: The facility aims to achieve full compliance within one week of implementing the corrective action plan.
How the facility will monitor its corrective actions to ensure that the deficiency does not recur: The Director of Maintenance will be responsible for ongoing monitoring of the preventative maintenance system logs to ensure that weekly checks are being documented. The QAPI committee will review the audit results and make further recommendations as needed.
Deliverable #2
Next, as a leadership team, review the notes and SWOT analysis from the three elopement drills you held last week.
What are the trends you identified in your SWOT analysis after the drills?
What are your areas of risk?
Where did we not follow our processes and policies?
Are there processes that were followed but did not work as intended?
Create an outline of formal education to be completed for your entire team, including frontline staff. The outline is your second deliverable.
Your second task is to schedule training during all three shifts for next week, week 4.
Identify who the trainers will be, when the training will occur, and how you will document the training.
Schedule training for the second half of week 4 so you can use the first half of the week to turn your training outline into the training materials and plan.
To summarize, this week you will...
-Pull together your leadership. Have them each create QAPI action plans to address any processes or policies the team identified as being out of compliance during week 1's exercise. Plans are due by Wednesday and each leader should be prepared to report out on their progress by Friday.
-Using the SWOT analysis from the elopement drills you held last week, create an outline that can be utilized to develop a formal education for all staff.
-Schedule training for your team on all three shifts to occur the following week, during week 4.
Stay tuned for next Sunday's newsletter.
Whenever you're ready, there are a couple of ways I can help you.
- Leverage our partnership with CEUSrEZ and purchase NAB-approved, online, self-paced, continuing education courses at a 20% discount here.
- Coming soon in January 2024. Stay tuned!
- Coming soon in February 2024. Stay tuned!
