HOW
Represents the Rules
How will the facility ensure the specific processes and procedures are followed consistently to prevent recurrence?
It is the internal control component of the corrective action plan.
It answers the question, what are the specific checks and balances in place to confirm the “What" is taking place?
It shows what controls exist to ensure that the process is followed and what actions are required to prevent recurrence.
Practice Question:
When you think about a facility’s enrollment procedure, what comes to mind when you think about all the steps they should do to ensure enrollment paperwork is up to date?
The how is “how the work is getting done.”
For updating enrollment paperwork, we need to ask:
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How does the facility determine when updates are needed?
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How does the facility determine that all required updates are received?
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How does the facility determine that the enrollment paperwork is current and complete?
WHEN
When Will It Be Implemented?
When will the processes and procedures be implemented and at what frequency?
“When” identifies when the corrective action, process, and ultimately the new policy and procedure are going to be fully implemented in the facility.
This must be a specific date, not just a month and year.