SAMPLE POLICY WORK

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Compliance and Regulatory Affairs: –

Data from incident investigations are used to demonstrate compliance with TN.0357.R05.00, TennCare guidelines, and state regulations during external audits.

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Human Resources: –

All incidents that potentially involve disciplinary actions are integrated into the HR review process, ensuring that staff disciplinary measures align with our progressive, non ‑ punitive approach.

k. Procedural Workflow and Implementation Checklist

The following step-by-step workflow summarizes the overall incident reporting and investigation process:

Incident Occurrence:

– Any staff member witnessing or experiencing an incident immediately notifies their supervisor or uses the designated emergency hotline. 2. Initial Incident Report Filing: – Upon notification, the staff member completes the Incident Report Form via the Secure Electronic Incident Management System (SEIMS). – The report includes all critical details such as date, time, location, description, involved parties, and immediate corrective steps taken.

Internal Notification:

– The direct supervisor and departmental manager are alerted automatically by the SEIMS system upon submission of the report. – The incident is escalated to the Quality Assurance Team for review if categorized as moderate to severe. 4. Preliminary Investigation: – The designated Incident Response Team convenes immediately or within a set timeframe (e.g., 15 minutes for severe incidents) to gather additional information. – Witness statements, electronic logs, and observational data are collated. 5. Data Collection and Root Cause Analysis: – The assigned investigator follows up with all involved parties and conducts a root cause analysis meeting. – The investigation covers chain-of-event analysis and systematically identifies contributory factors. 6. Corrective Action Development:

– A detailed corrective action plan is drafted based on the identified root causes.