A risk manager comes to thequality improvement (QI) professional and requests help to improve compliance with a corrective action plan. How can the…

The most appropriate role for a Quality Improvement (QI) professional is to use systematic problem-solving tools to understand why a process is failing. A corrective action plan is a process, and non-compliance indicates a failure in that process. A root cause analysis (RCA) is the standard QI methodology to investigate the underlying systemic reasons for non-compliance. By identifying the root causes (e.g., lack of training, confusing instructions, resource constraints), the QI professional can help the risk manager develop more effective and sustainable solutions to improve compliance.

A. Disciplinary action is a punitive, managerial/HR function and is contrary to the non-punitive, systems-focused approach of quality improvement and a just culture.

B. Providing an analysis to a committee is a reporting function; it describes the problem but does not actively help to solve the underlying reasons for non-compliance.

C. Checking compliance with national standards is an audit function that assesses external alignment, not the internal reasons for failure to follow a specific corrective action plan.

1. National Association for Healthcare Quality (NAHQ). (2018). HQ Solutions: Resource for the Healthcare Quality Professional (4th ed.). (Chapter on Process Improvement

Section on Root Cause Analysis

describes RCA as a tool to identify underlying causes of problems to prevent recurrence).

2. Agency for Healthcare Research and Quality (AHRQ). (2019). Patient Safety Primer: Root Cause Analysis. PSNet. Retrieved from https://psnet.ahrq.gov/primers/primer/10/root-cause-analysis. (This source defines RCA as a structured method used to analyze serious adverse events but also applicable to understanding process failures).

3. Institute for Healthcare Improvement (IHI). (n.d.). Root Cause Analysis (RCA). Retrieved from http://www.ihi.org/resources/Pages/Tools/RootCauseAnalysis.aspx. (The IHI describes RCA as a method for identifying the underlying system problems that contributed to an error or process failure).