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Why does your company need to implement a Corrective Action Plan (CAP) process? Have you ever wanted to get the right people in the room, collaborate and discuss feasible next steps and ensure they follow through? Well then, initiating a CAP process for your team is something you can and should do. As defined by Centers for Medicare and Medicaid Services (CMS), a CAP is “a step-by-step plan of action that is developed to achieve targeted outcomes for resolution of identified errors.” This is “in an effort to develop and implement a plan of action to improve processes or methods ensuring all outcomes are more effective and efficient.” In addition, the CAP will “achieve measurable improvement in the highest priority areas” and “eliminate repeated deficient practices.” A CAP document will provide ownership and accountability for a process within specific teams. Required next steps and specific timelines will resolve any issues at hand and will prevent it from occurring in the future. This document is then delivered and agreed upon by the client. 

Why Every Company Needs a Corrective Action Plan (CAP) Process

Identify Problem & Root Cause and Gather Metrics 

As the first step in the CAP process, when the issue is identified, the team should investigate the root cause to find why and how the issue occurred. The root cause includes an impact analysis to determine how many records were affected. These metrics will assist the Subject Matter Expert (SME) in knowing the true impact of the issue and the best way to remediate it. These metrics should also be included in the CAP document to inform the impacted clients of how many members the issue affected. For example, let’s say a software company released functionality to implement auto-payments for their account balance to run on the 4th of each month for members. On the 4th, it was identified that the functionality was not working appropriately.

Collaborate on Next Steps

The SMEs would then investigate and identify that a bug existed in the functionality making it apply the payment at a later day in the month due to a manual coding error. SMEs and other internal stakeholders would collaborate and solidify the root cause. Once the issue is identified, the team will identify what the impact was. The SMEs would then investigate which member accounts were affected by the faulty functionality and provide the number of members and a list of member information for the CAP document. Meetings would be held to make sure all next steps are in place.

Remediate Issue & Complete Prevention Plans 

After the root cause and metrics sections are completed, the next step is to correct the issue within the Remediation section of the CAP. This step is to ensure no further records are affected, and all impacted records have been resolved. The following step is to put measures in place to confirm the issue doesn’t occur again, involving the Prevention section. This section of the CAP is to provide steps to update the process to prevent the same issues from occurring again. By having improved processes in place, the team will be able to confidently confirm the same issue doesn’t occur. To ensure the prevention tasks are being completed correctly, the Compliance team will audit the process.  

Audit the Process & Close Out CAP 

To audit the process, the Compliance team will manage and monitor how the next steps are being completed and if the specific outcome was accomplished. By ensuring the prevention tasks are being completed on time and correctly, this will evaluate the progress of the CAP’s next steps. This audit is done to follow-up with the SMEs to confirm that all work has been completed and the issue will not arise again. Once the audit is completed, the CAP can be closed out with the client and internal team approval after a final report is provided to the client or the last prevention item has been completed. 

Kaizen Event 

Softheon develops CAPs to ensure if issues occur, the team has next steps in place to resolve and remediate so it won’t happen again. To further improve our processes, Softheon also also holds Kaizen events to get all internal stakeholders in the room to discuss productive change for our clients. As defined by the Kaizen Institute, a Kaizen is continued improvement that involves everyone from managers to employees in day to day operations. A Kaizen event strives to improve a process for the better and prevent any abnormalities to occur so teams can operate efficiently and effectively. 

So why should a company start using CAPs? It’s simple. A company should be proactive instead of reactive. If you set up a process in place for the future, you’ll have better products and less stress involving the workplace. In addition, companies use CAPs throughout their organization to provide strategic next steps for internal teams. This way, all internal stakeholders are in a room together, speaking about the problem at hand, collaborating on how to fix it and setting up measures to implement and prevent the issue. Collaborating and brainstorming with all involved team members in the room can provide insight for all products experiencing similar issues and build a way to work through on a consistent timeline. CAPs shouldn’t be viewed as a negative, they should be used to set the team up for success in the future. 

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