County of Los Angeles Corrective Action Plan Program Enhancements

1. County of Los Angeles Corrective Action Plan Program Enhancements John Sterritt CEO Risk Management

2. Agenda • What is a Corrective Action Plan • What is a Summary Corrective Action • Plan • CAP/SCAP Confidentiality

3. CAP/SCAP Program Effective May 18, 1999, the Board of Supervisors (Board) required the completion of a comprehensive Corrective Action Plan (CAP) for all liability settlements over $100,000. Effective November 1, 2007, the Board required a Summary Corrective Action Plan (SCAP) for liability settlements in excess of $20,000 ($100,000 Medical Malpractice).

4. CAP/SCAP Process The CAP/SCAP Process: Assessing the CAP/SCAP’s effectiveness Researching the cause of loss event Developing a CAP/SCAP Implementing the CAP/SCAP

5. The County of Los Angeles CAP/SCAP Process Following the Loss Event:

6. What is a Corrective Action Plan • A CAP is a collection of corrective actions to mitigate or eliminate the causes of the loss event. • The plan includes: • Specific corrective actions • Who is responsible for the entire plan • Criteria to measure plan effectiveness Although no specific CAP form is mandated, CEO has a recommended form that all departments can use.

7. What is a Summary Corrective Action Plan A Summary Corrective Action Plan (SCAP) provides the Board an executive summary of the corrective actions taken by a department and is required for all liability settlements over $20,000 (>$100,000 for medical malpractice). Specific form is mandatory.

8. What is a Summary Corrective Action Plan A SCAP is intended to be read in conjunction with the associated Case Summary prepared by the County Counsel’s Office. The Case Summary states the salient facts of a case, and the SCAP informs the public of the corrective actions taken by a department. All SCAPs and all Case Summaries are public documents – some are confidential. SCAPs and Case Summaries are not prepared for the following two types of settlements: • Litigation involving multiple parties, where the settlement is with • some but not all of the plaintiffs • Requests to make statutory settlement offers (California Code of • Civil Procedures Section 998 and Federal Rule of Civil Procedure • Rule 68 offers)

9. What is a Summary Corrective Action Plan • Effective November 1, 2007 • Purpose • Executive Summary of corrective actions taken by a department • Required for claim settlements in excess of $20,000 • ($100,000 for Medical Malpractice) • Included in Claims Board settlement documents • Confidentiality • All SCAPs are public documents, none are confidential • If there is a question as to confidentiality, please consult County Counsel

10. What is a Summary Corrective Action Plan Document that outlines the following: • Root Causes • Corrective Action Steps • Applicability to Other • Departments

11. What is a Summary Corrective Action Plan Form Instructions The intent of this form is to assist departments in writing a corrective action plan summary for attachment to the settlement documents developed for the Board of Supervisors and/or the County of Los Angeles Claims Board. The summary should be a specific overview of the claims/lawsuits’ identified root causes and corrective actions (status, time frame, and responsible party). This summary does not replace the Corrective Action Plan form. If there is a question related to confidentiality, please consult County Counsel.

12. What is a Summary Corrective Action Plan Section One: Event description

13. What is a Summary Corrective Action Plan Section Two: Root Cause and CAP Steps Briefly describe the root cause of the claim/lawsuit: Briefly describe recommended corrective actions: (Include each corrective action, due date, responsible party, and any disciplinary actions if appropriate)

14. What is a Summary Corrective Action Plan Section Three: CAP/SCAP Applicability State if the corrective actions are applicable to only your department or other County departments: (If unsure, please contact the Chief Executive Office Risk Management Branch for assistance) Potentially has County-wide implications. Potentially has implications to other departments (i.e., all human services, all safety departments, or one or more other departments). Does not appear to have County-wide or other department implications.

15. What is a Summary Corrective Action Plan Section Four: Review and Approval Signature: (Risk Management Coordinator) Signature: (Department Head)

16. County CAP Data Table 1. Number of CAPs for Tort Liability Claims by Fiscal Year (FY)

17. CEO CAP/SCAP Programs The CEO offers a number of CAP/SCAP training opportunities. Since 2005, the CEO has trained over 500 County employees in the development and implementation of CAP/SCAPs. The CEO published the Corrective Action Plan User’s Guide to enhance development of CAP/SCAPs within the County. In addition, CEO Loss Control and Prevention prepares Departmental Needs Assessments to assist in the identification of CAP/SCAP issues.

18. CAP Confidentiality • CAPs are generally not confidential and will be released to the public • Exceptions – the following CAPs are marked confidential and are not released to the public: • DHS will continue to mark medical malpractice CAPs confidential • Employment related CAPs will continue to be marked confidential • Before marking other CAPs confidential, a department needs to discuss the basis for the confidentiality with County Counsel • CAPs will only be marked confidential when there is a specific statutory basis for the confidentiality • CAPs are not to be marked confidential based on Attorney-Client Communication or Attorney Work Product

19. SCAP Confidentiality All SCAPs and all Case Summaries are public documents – some are confidential. SCAPs and Case Summaries are not prepared for the following two types of settlements: • Litigation involving multiple parties, where the settlement is with some but not all of the plaintiffs • Requests to make statutory settlement offers (California Code of Civil Procedures Section 998 and Federal Rule of Civil Procedure Rule 68 offers) If there is a question as to confidentiality, please consult County Counsel.

20. Questions?