Results of monitoring of the completion of action items derived from the root cause analysis (RCA) of potentially adverse events was reported to the UHS Quality Improvement Committee in November 2007. We measured the time frame from creation to completion of the action items with a goal of completion of all the items within five weeks as an indicator of how the RCA was being used to improve the quality of processes and potentially reduce risk.
In the process of gathering data, we discovered that we could improve our documentation of discussions in meeting minutes to support communications and educational activities relating to action item. We are meeting our goal 80-90% of the time. Factors identified which influence meeting goals are the need for reminders, oversight and tracking of progress by the RCA participants.
September 9, 2008
- Lynn Huddell, Member
- Nancy Lambert, Member