Just the FACTs – FACT News – Guidelines for Corrective Action Plans to Improve Low One-Year Survival

Guidelines for Corrective Action Plans to Improve Low One-Year Survival

Posted in :: 2016 Volume 2 :: Wednesday, October 12th, 2016

The FACT Clinical Outcomes Improvement Committee reviews corrective action plans submitted by Clinical Programs not meeting expected one-year survival. Development and review of these corrective action plans is new to Clinical Programs and to FACT. The emphasis of the committee is to help programs identify ways to improve their outcomes for patients, and it appreciates the programs who submitted the first plans and provided more information when requested. After several months of reviewing corrective action plans, the committee has articulated its expectations for these plans using six guidelines:

  • The corrective action plan must identify specific causes of death.
  • The corrective action plan must provide quantitative data.
  • The assessment must identify reasonable causes of the low one-year survival rate.
  • The corrective action plan must address the identified causes.
  • There must be a measurable outcome improvement.
  • The program must provide updates on corrective actions at the time of inspection, at the time of annual reporting, or as otherwise directed by the committee.

The essential point of these guidelines is to help Clinical Programs write corrective action plans that convey the thought process they employed to identify root causes and implement remedial measures. It is tempting to jump to conclusions and take actions assumed to be beneficial, but those actions will not be effective if incorrect conclusions are made. By providing quantitative data about causes of death, it will be clear to both the program and the FACT committee what the underlying issues are and where opportunities for improvement exist.

FACT will continue to provide advice and examples related to improving clinical outcomes. The next Quality Management Series module is dedicated to Outcome Analysis, and will consist of four webinars from November through February that focus on clinical outcomes. Example corrective action plans, used with permission from Clinical Programs, will also be posted on the FACT website this fall.