Compliance with LTC Homes Act - a risk-based approach
Channel: tcmc Quality Management Services
Date: 2015-02-24

Compliance with Ontario LTC Homes Act - a risk-based approach

Proposed strategy is the well-known PDSA, Plan, Do, Study, Act, sometimes called Plan, Do, Check, Act.

The underlying principles and assumptions for this proposed action plan are to take a risk-based approach in dealing with potential findings of non-compliance: 
1st, non-compliance that could result in harm to residents;
2nd, non-compliance that would likely result in high dissatisfaction on the part of residents;
3rd, non-compliance that could result in orders from the inspector due to repeated infractions.
 
Plan: Formulate for approval
1. Compose compliance task team
2. Identify any potential, avoidable critical incidents 
3. Identify potential, likely complaints
4. Retrospective review: repeat findings
5. Identify gaps with QIP
6. Cost-Benefit Analysis: action vs. no-action
 
Do: Pilot Preventive Actions
7. Prospective Root Cause Analysis (Critical Incidents - Step 2)
8. Perform FMEA
9. Review existing mitigations
10. Prospective Root Cause Analysis (Complaints - Step 3)
11. Prospective Root Cause Analysis (Findings - Step 4)
12. Look for ‘Quick Wins’
 
Study: Measure and Monitor
· Overlaps with Do phase
· Begins with first implementation
· How measure for effectiveness and impact?
· Report results
 
Act: Refine and Implement
· Minimize negative impact
· Improve effectiveness and efficiency
· Cycle back; Incorporate into QIP