1 / 13

2012 Navy Medicine Audit Readiness Training Symposium

2012 Navy Medicine Audit Readiness Training Symposium. Plan of Action and Milestones (POA&Ms) DQ Statement Comments A How-To Exercise RE-T-3-D. Context, Purpose, Outcome. Demonstrate the process to develop effective plans of actions and milestones.

morty
Télécharger la présentation

2012 Navy Medicine Audit Readiness Training Symposium

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 2012 Navy Medicine Audit Readiness Training Symposium Plan of Action and Milestones (POA&Ms) DQ Statement Comments A How-To Exercise RE-T-3-D FOR OFFICIAL USE ONLY

  2. Context, Purpose, Outcome • Demonstrate the process to develop effective plans of actions and milestones. • Educate audience on properly defining the issues, conducting efficient root cause analysis and developing actions and timeliness to correct program weaknesses. • Audience will report effective POA&Ms to efficiently correct weaknesses in the DQMC and MEPRS programs. FOR OFFICIAL USE ONLY

  3. What is a POA&M? • A document designed to identify the root cause of a discrepancy, the actions to be taken to resolve it, and a timeline for when the actions will occur. • POA&Ms are required when a Data Quality metric is non-compliant for 3 consecutive months. POA&Ms can be closed once a metric show 3 consecutive months of compliance. • Standard format also includes details such as action officers, risks, dependencies, and quarterly status updates. FOR OFFICIAL USE ONLY

  4. Identifying the Issue • Issues are a broad summarization of what is causing the metric to be non-compliant across the whole period of non-compliance. • Issues are not a restatement of the metric! • Issues should not be confused with Root Causes. • Best explained by example: • Metric: Gas gauge reads empty. • Issue: Reading is incorrect, the tank is actually full. FOR OFFICIAL USE ONLY

  5. Root Cause Analysis • A Root Cause Analysis (RCA) helps identify the what, how and why an event occurs or has occurred. Knowing why a metric is non-compliant is needed in order to put corrective actions into place. Root Cases have four primary characteristics: • Underlying Causes • Reasonably Identified • Controlled by Management • Reasonably Prevented • Example: Faulty wire on the gas gauge cases it to incorrectly read the tank fuel level. FOR OFFICIAL USE ONLY

  6. Risks and Dependencies • Risk is defined as the probability or threat of a damage, injury, liability, loss or other negative occurrence that is caused by external or internal vulnerabilities, and that may be neutralized through preemptive action. • POA&Ms are used to either identify the risks of inaction (if the root cause is not addressed) as well as the risks of action (what might happen if the POA&M is implemented). • Risks should never be identified as “a failure to meet the metric”. • Gas gauge example: The risk of a gas gauge reading Empty is not that it will continue to say Empty, but that you might run out of gas and be stranded. • Dependency is defined as the relationship between conditions, events, or tasks such that one cannot begin or be-completed until one or more other conditions, events, or tasks have occurred, begun, or completed. • Gas gauge example: To fix the gauge, you are dependent upon an electrician. FOR OFFICIAL USE ONLY *Definitions blatantly plagiarized from: http://www.businessdictionary.com/

  7. Action Items • Action items are discrete activities that an MTF will perform. • Must have a definite start/stop. Actions can be used to change a recurring process, but the recurring process itself is not the action. • Must have an Action Officer assigned. Do NOT default everything to the DQ Manager! • Action items are specifically address a Root Cause. FOR OFFICIAL USE ONLY

  8. Current POA&M Format FOR OFFICIAL USE ONLY

  9. Let’s Look At What NOT To Do….. Using what you have learned from the previous slides, can you identify why this is not a good POA&M? FOR OFFICIAL USE ONLY

  10. Example of a Proper POA&M FOR OFFICIAL USE ONLY

  11. Data Quality Statement Comments • Comments are required for metrics that fall outside the compliance range (usually less than 95%). • Comments must identify the Issue and Corrective Action for the particular month. Process is the same as for a POA&M, but for the specific data month. • Do Not!! • Restate the metric. • Put the same comment each month. • Put corrective actions that say “continuing to monitor” or “continuing to train”. FOR OFFICIAL USE ONLY

  12. Some Examples of Not-So-Useful Comments FOR OFFICIAL USE ONLY

  13. Questions? * Picture copied from icanhascheezburger.com FOR OFFICIAL USE ONLY

More Related