Corrective action is an aspect of quality management that focuses on rectifying a task, process, product, service, or individual behaviors when any of these factors produce errors, deviate from the original plan or benchmarks. Corrective actions can be thought of as an improvement an organization uses to eliminate undesirable or ineffective outcomes. In this seventh, and last installment, on our series for oncology quality studies, we are going to look at using corrective action plans after the quality study is completed to achieve lasting improvement.  

Corrective action has many applications in healthcare and may be used in different ways depending on the quality study that was conducted and its observed results. Its processes include clear identification of the problem and thorough documentation of the resources and steps that are required to mitigate its root causes and observed symptoms. The plan should address the critical problems and recurring issues, such as safety, security, supplies, and treatment-related circumstances when any member of the team, patients or guests communicate an unsatisfactory response.    

Taking the time to develop a corrective action plan may seem cumbersome or bureaucratic. But it offers several benefits:

• It walks the team through the process so there is no need to reinvent the problem-solving wheel.
• It documents the steps that need to be taken to solve the problem already identified by the quality study.
• Corrective action plans build transparency into the activity and empowers all members of the team to act to grow the cancer program to a higher level.
• It captures and identifies changes or new aspects of improvement that can be used in the future.

What is Included in a Corrective Action Plan?

A corrective action plan is a stepwise document that describes how the problem will be resolved and monitored. It details the resources needed to correct the causes of the problem in a cost-, time- and resource-efficient manner.

The plan should be specific and describe the interim measures that will be taken to mitigate the problem. Like other components of the quality study, the plan should specify the service, program or processes that require change, how the change will be implemented and the timeline for accomplishing the goal. Unlike the quality study the corrective action plan should clearly identify the staff, services or departmental resources needed, the specific tasks to be completed to accomplish the goal, identify deliverables, and assign due dates and deadlines to complete the process in a timely manner.

The plan should also describe what the process will look like when the goal is achieved and what steps are to be taken if new problems or barriers are encountered along the way. Effective action plans include the following elements:

• Stakeholders,
• Resources available to solve the problem,
• Constraints,
• Due dates,
• Metrics for completion, and
• Status updates, to whom, and reporting frequency.  

CoC-accredited facilities should include the same members of the quality improvement team, the Cancer Liaison Physician (CLP) and cancer program leadership. Involving the entire team in the process enhances engagement in the cancer program and supports greater innovation, organizational commitment, and retention.

Summary

In summary, completion of a quality study provides data to serve as the next step in the quality improvement process – correcting and improving the problem that initially prompted the quality study to be conducted.   

The Cancer Committee must be involved not only in the quality improvement study processes, but they should take an active role in creating the corrective action plan and monitoring outcomes at routine intervals to determine effectiveness.   If conducted properly, the corrective action plan will almost always provide new details and information that can be used for future quality studies. It is this cycle of performance improvement that leads the organization to developing and maintaining high levels of service and patient-centric care.  

About This Series

If you would like to review the previous installments in this series, please click on the link(s) below:

• Part 1: Creating a Team of Subject Matter Experts
• Part 2: Identifying the Problem
• Part 3: Planning and Methodology
• Part 4: Conducting the Study According to the Methodology
• Part 5: Preparing the Summary Analysis
• Part 6: Benchmarking to Measure Performance
• Part 7: Corrective Action Plans for Lasting Improvement