HCA460: Health Care Administration Capstone #4 Template

HCA460: Health Care Administration Capstone #4 Template

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Executive Summary to the CEO

Your Name

University of Arizona Global Campus

HCA 460: Health Care Administration Capstone

Instructor’s Name

Date (spelled out: January X, 20XX)

Executive Summary to the CEO

In this introductory section, begin by first stating your purpose for writing the Executive Summary to the CEO. Next, preview the main parts of your report so the reader knows what to expect. End this section with a statement that indicates the thesis or main conclusion of your paper.

Part 1: The Sentinel Event

Scenario Summary and Timeline of the Events

In this section, begin with a summary of the facts related to the sentinel event. Be sure to describe the event. Also include the staff involved. This information should be the same or very similar to the scenario you created for the Week 2 Discussion and continued in the Week 3 Discussion.

Next, discuss the timeline events from the initiation of the error through the resolution. This will vary depending on the sentinel event. Address when and/or where the error occurred, when it was detected, when it was reported, and to whom it was reported.

Procedural Errors

Evaluate the procedural errors. This is where you will need to identify the point in time where the error should have been detected before it occurred. What part of the process or procedure was missed that contributed to the sentinel event?


Analyze the accreditation agency requirements. Identify which agency would be involved (e.g., OSHA, ACHA, CMS, CDC, CLIA, TJC, AHCA, state agencies). Define the agency’s purpose and discuss the agency’s reporting expectations based on the incident.

Part 2: Root Cause Analysis (Fishbone Diagram)

(Note: This is a sample. Do not replicate the contents of this exact diagram. Right click on the image and select CUT from the list to remove it.)

For this section, you will create the CQI Tool (Fishbone), complete the tool, copy (or take a screenshot of) the completed work, and paste the completed diagram here. If you are unfamiliar with the Fishbone, please refer to the Using Quality Improvement Methods for Evaluating Health Care article by Siriwardena (2009). In addition, as a learning resource, the CQI tool listed below is hyperlinked to the Institute for Health Care Improvement website, which discusses and illustrates an example of the Fishbone. Tools: Cause and Effect Diagram

Part 3: Root Cause Analysis Report

In this section, you will create a root cause analysis. In this first paragraph, you will identify the data elements you would collect to determine the cause and give your rationale for choosing these data elements. Data elements are the numbers that are used to identify and track the happenings within the organization. For example, if the sentinel event occurred due to insufficient staff on duty at the time, the number of staff members on duty is a data element.  

Probable Cause

Next, identify the probable cause. This may include process failure, human error, cultural biases, policy error, systems error, technology failure, or some other issue that may have contributed to your sentinel event. Include any or all of the following subsections in completing the probable cause portion of your report.

Human Factors

What human factors were relevant to the outcome?

Process Errors

What process errors were relevant to the outcome?

Missed Steps

Were there any steps in the process that did not occur as intended?

Equipment Performance

How did the equipment performance affect the outcome?

Other Areas

What are the other areas in the health care organization where this could happen?

Staff Performance

Did staff performance during the event meet the expectations?

Corrective Action Plan

Here, develop a corrective action plan that is geared towards eliminating future events. Explain the steps of implementing the corrective action plan. Writing at least a paragraph for each section, and discuss the elements below in your response.

Risk Reduction Strategies

            Identify the best risk reduction strategies related to your scenario. What will help the staffing team avoid this kind of event in the future?

Improvement of Processes or Systems

How can the processes or systems be improved to eliminate future events?

Communication Barriers

Discuss the communication breakdown that may have contributed to the sentinel event. What barriers may have occurred to cause the breakdown in communication? Some of these may include residual intimidation, reluctance to report to a coworker, missing information at time of transition of care, etc.


What training should be implemented to eliminate future events? This may include orientation, professional development, cultural competency, skills training, in-service, etc.


What equipment should be considered to eliminate future events? This should include the technology, maintenance, and updates.

Policies and Procedures

What new or revised procedures should be considered to eliminate future events?

Monitoring Process

            Describe the monitoring process that will be used to evaluate the success of the corrective action plan.

Reallocation of Budgetary Resources

Analyze the components that may require the reallocation of budgetary resources. In this paragraph or series of paragraphs, you will want to consider legal action that may occur against the organization due to the sentinel event, public relations (reputation leading to decreased revenue), equipment and supplies, training and education, patient-centered communication methods (informed consent, procedural education, patient involvement in the procedure [identify or mark the location of the surgical site]), staffing time for patient education, and increasing staffing related to workload balance (reallocating staff, role responsibilities, hiring temporary or permanent staff). Include your rationale for each action you recommend. Additionally, explain how each part will benefit the organization (make a connection between the recommendations and how it will help in avoiding the sentinel event in the future).


Restate the conclusion or overall recommendation of the report. Recap the main points.

HCA460: Health Care Administration Capstone


Include at least eight scholarly or credible sources in your assignment. Use APA Style to format your sources on the References page. You must include in-text citations throughout your paper to show your reader what information you used from outside sources.

Author, A. A., Author, B. B., & Author, C. C. (Year). Article title. Journal Title, volume #(issue #), page range. http://doi.org/xxx.xxx.xxx.xxx

Author, A. A. (Year, Month Day). Webpage title. Website Title. http://(URL)

Title of Organization. (Year, Month Day). Webpage title. Website Title. http://(URL)

Author, A. A. (Year Published). Title of book: Subtitle of book (edition, if other than the first). Publisher Name. https://doi.org/xxx.xxx.xxx (ebook’s DOI, or https://(URL) if not contained within a database and DOI is unavailable)

Author, A. [Screen name, if different]. (Year, Month Day). Title of video [Video]. Platform Name. https://(URL)

*In the final version of your assignment, be sure to remove all the hints (blue boxes) and directions within the template.

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HCA460: Health Care Administration Capstone


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