2. Measuring the size of the problem with current data, identifying the absolute frequency of occurrence over recent periods of time, and remembering that these issues are often so risk-intensive that even one occurrence is unacceptable.
3. Identifying the specific causes for the occurrence from all vantage points: leadership, personnel policy, standardized procedures, information systems, and technology, communication pathways, management and supervision philosophies and processes, teamwork and coordination, staffing patterns and levels, equipment, care environment, and individuals.
4. Targeting interventions to the most important, modifiable cause.
5. Embedding interventions into routine work processes.
Verbal or Written threats
Employee to employee
Measures of Quality (cholesterol screening)
Measures of Financial Performance (cost per member)
Accreditation with follow-up survey
Preliminary denial of accreditation
Denial of accreditation
* medically necessary
* preformed in the most efficient, effective & economical manner
Acknowledging the losses
Providing information and asking for feedback
Marking the endings
Managing the transition
Clarifying and reinforcing the beginning
Celebrating the successes