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2012 Navy Medicine Audit Readiness Training Symposium

2012 Navy Medicine Audit Readiness Training Symposium

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2012 Navy Medicine Audit Readiness Training Symposium

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  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:

  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


  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 FOR OFFICIAL USE ONLY