4 Ws and 1 H
Let’s take a close look now at how you can use the 4 Ws and 1 H approach to help your facilities write new policies or update old ones as part of a Corrective Action Plan.
WHAT
WHO
HOW
WHEN
WHERE
WHAT
Identifies Problem
The “what” identifies what specific process and procedure the facility will implement to address the root cause of the noncompliance.
This noncompliance could be the result of the sponsoring organization’s monitoring review of the facility, the State agency reviewer conducting a monitoring review or noncompliance discovered internally by the facility realizing that they need to update a process due to an update in Program guidance or the sponsoring organization’s requirements.
Practice Quiz Question:
The noncompliance is failure to update enrollment records annually.
WHO
Is Responsible for Implementing the "What"
The “who” identifies which position is responsible for implementing the “What.” It answers the question, what position is directly responsible for ensuring that the processes and procedures implemented for addressing the root cause of the noncompliance is implemented?
It is important to tie the process and procedure to a position because a person may change over time, but that function needs to be tied to a position that will not change over time.
The “who” or position needs to be fully trained and capable of implementing the new process and procedure, feel empowered and have authority and support to successfully implement the process and procedure.