As a nurse leader for the past 20 years, I have witnessed the spectrum of experiences when it comes to plans of correction. Whether it's a quality improvement initiative or a compliance issue demanding swift action to meet survey requirements, the good, bad and ugly I’ve seen it.
Picture this:
I accepted a position as a nurse consultant for a skilled nursing facility that was struggling to achieve compliance. Despite having a dedicated team of nurses and a compassionate nurse leader, there was one problem - the nurse leader had never created a plan of correction.
She guided me to her office, where I was greeted by a sight that left me spinning in circles. The walls were adorned with poster boards displaying an overwhelming number of small tasks for the nursing team to implement, monitor, and audit. The room was saturated with action items meant to address compliance issues. It was a recipe for failure, and unfortunately, that's exactly what was happening.
The key to achieving results lies in making the process feasible and attainable. The real way to drive results is to make it doable.
Are you facing compliance issues? Do you need to address problems or implement new strategies to enhance your processes? The topic of writing a plan of correction (POC) wasn't covered in our nursing coursework. However, I'd like to provide you with some fundamental guidelines on how to create an effective POC.
Think care plan but about a system rather than a patient.
As nurse leaders, we often find ourselves caught up in the process of writing plans of correction that end up becoming lengthy, convoluted documents packed with unnecessary information.
These plans become difficult to implement and can lead to chaos in our teams. But, a clear and concise plan of correction leads your team to success.
In this post, we will take a closer look at how to write a plan of correction that puts action items in place without creating chaos.
Identify the Root Cause
The first step in writing a concise plan of correction is to identify the root cause. This means digging deeper to identify the underlying problem that is causing the issue.
Once you have identified the root cause, you can then develop a focused plan of action that will address the problem. Avoid going into too much detail or adding irrelevant information that could confuse the reader. Stick to the actions that need to be taken, and focus on the solution.
When it comes to uncovering the root cause, you may be familiar with the fishbone method or the five whys technique. There are several methods to find the root cause, explore, try them out, find out what works for you or the one your company prefers. Personally, I find the five whys to be the most straightforward approach for reaching a solid starting point when initiating a POC.
Five Whys is a collaborative process used to draw out the root cause of a challenge. By asking “Why?” five times, you will dig deeper into your problem and uncover the underlying issue. This technique helps to identify what needs to be fixed in order for the issue not to occur again in the future.
Set Objectives and Targets
The second step is to set objectives and targets. By setting clear objectives, you can determine what your team will achieve as a result of implementing the plan of correction. These objectives should be specific, measurable, achievable, relevant, and time-bound. Setting targets allows you to measure progress and ensure that your team is working towards achieving the set objectives successfully.
Develop a Clear and Concise Action Plan
The third step is to develop a clear and concise action plan. The plan should be structured in a way that makes it easy to understand, implement, and monitor progress. Start by outlining the steps that need to be taken to achieve the objectives set in step two. Be sure to focus on the key actions that will make the most significant impact and avoid adding too much detail that could make the plan overwhelming. Think macro system, not micro-manage.
Assign Responsibilities
The fourth step is to assign responsibilities. It is crucial to identify who will be responsible for ensuring the plan is implemented correctly. By doing so, you can clearly define roles and responsibilities, which helps to ensure that everyone is held accountable. Assigning responsibilities also allows your team to take ownership of the plan of correction, which will help to ensure its success.
Monitor Progress and Adjust as Needed
The final step is to monitor progress and adjust as needed. It is essential to keep track of progress regularly and make adjustments when necessary. This will help you to identify any issues that arise quickly and make changes as needed to achieve the set objectives. Having regular check-ins with your team can be an effective way to monitor progress and adjust as needed.
Here is an example of a nursing plan of correction:
Problem: Staff not answering call light within 5 minutes
Audit: How can we ensure that the staff is promptly responding to call lights? Conducting tests or audits should be included in your plan of correction to gather data on the current situation and set goals for improvement. For instance, during a 24-hour audit, we observed a call light response time exceeding 5 minutes in 60% of cases.
Objective: Ensure that staff respond to call lights within 5 minutes of activation, with a clear target. For instance, the aim is to answer call lights in under 5 minutes, for a 100% success rate. Set a clear goal like: In the next 30 days.
Actions:
- Conduct a 5 Whys analysis with the staff assigned to the call light area.
- Address the root cause. (For example, if the staff have unclear break schedules, develop a break schedule plan with them.)
- Provide additional training to the staff on call light procedures.
- Reinforce expectations through verbal reminders.
- Monitor staff performance and document findings in a log book or tracking service.
- Report the findings to the quality assurance team along with follow-up plans and actions.
Responsibilities: Assign a Manager responsible for ensuring procedures are developed
- Develop policy/procedure or review current plan for revision needs
- Implement training program for staff to review and understand the policy/procedure
- Monitor compliance with the policy/procedure repeat tests or audits
Questions to ask yourself when starting the action plan:
- What happened or might happen?
- Who did it happen to?
- Who is at risk for it happening to them (audit)?
- How can you stop it from happening?
- How will you monitor that the change is working?
- Who do you report it to?
- How long will you monitor to ensure it worked?
Example of Plan of Correction:
Patient A and B call lights not answered after 6 minutes per surveyor stopwatch.
Nurse manager completed an Audit of all patients on the unit with a 60% rate answered after 5 minutes.
Nurse leader led Root Cause Analysis with staff conducted on this date.
Plan of Correction: Nurse leader Educated staff by this date on policy and procedure by this date.
Unit manager Implements a new break schedule by this date.
Unit manager will Audit each week until 100% compliance has been obtained.
Nurse leaders will report results each month to the quality team for the next three months.
Take a deep breath! You got this! Focus on one action at a time in your plan, set clear objectives and targets, assign responsibilities, and monitor progress regularly. By doing so, you can ensure that your team is heading in the right direction and following the right protocols without creating chaos.
Here's another resource, check out this 5 why tool at CMS.gov.
