SAMPLE POLICY WORK

– The investigator conducts interviews with all involved parties, including the complainant, witnesses, and staff members implicated in the grievance. – Further documentation from service records, supervisory notes, and training logs are collated to identify possible systemic issues. • Root Cause Analysis:

– After gathering evidence, a root cause analysis (RCA) is performed. This

step is essential for moving beyond the surface details to identify underlying issues such as inadequate staffing, poor communication protocols, or deviations from established policies. – RCA tools like the “5 Whys” or Fishbone Diagram may be employed to facilitate the analysis. • Drafting a Findings Report: – A detailed report summarizing the findings, identifying the root causes, and recommending corrective actions is prepared. – This report is shared with the Grievance Committee, which includes representatives from Quality Assurance, Compliance, and the relevant service department, for review and feedback.

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Interim Communication:

– The investigatory findings and anticipated corrective measures are communicated to the complainant (with sensitivity to confidentiality), ensuring that they are aware of the process and next steps.

Step 4: Corrective Actions and Resolution • Development of a Corrective Action Plan:

– The Grievance Committee, in collaboration with department heads and the Quality Assurance Team, develops a corrective action plan (CAP) based on the investigator’s recommendations. – The CAP includes specific actions to address the grievance at both individual and systemic levels, responsible parties, and timelines for implementation.

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Approval and Implementation:

– The CAP is reviewed and approved by executive leadership, ensuring alignment with organizational policies and regulatory guidelines. – Once approved, the CAP is communicated to all relevant staff, and corrective measures are implemented. This may involve additional training, process modifications, or disciplinary actions if required.

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Monitoring and Follow-Up:

– The Grievance Coordinator monitors the implementation of corrective actions through follow-up reviews, periodic audits, and continued communication with the complainant.