Title Slide Content Slides 1. Explain the history of the event. Include statisti

Title Slide Content Slides 1. Explain the history of the event. Include statistical details as to how often the event occurs across the country. Include the types of harm that can occur to patients during this event. 2. Discuss accreditation agency recommendations for avoiding this type of never event. Include a list of at least three accreditation agency recommendations. These can be from the Joint Commission standards, NCQA, CLIA, CMS, etc. Include your rationale for why you believe these recommendations are important to prevent the never event from occurring. 3. Analyze the cost/quality impact of the event on the patient and the hospital. Include potential harm to the patient. Include potential financial loss to the hospital (e.g., lawsuit, reputation, etc.). 4. Create a fishbone diagram to identify at least four possible root causes for the never event. You may use this accessible PPT fishbone diagram Download accessible PPT fishbone diagram. When you have added the details, in Normal view, put your mouse on the finished diagram slide in the left (slide navigation) column and right-click to copy the slide, then paste it into the left (slide navigation) column of your PowerPoint file. 5. Explain the procedures that should be followed to ensure the never event does not occur again at your hospital. Choose the best CQI method that could be used to eliminate the event from recurring (e.g., Lean, Six Sigma, Lean-Six-Sigma, PDSA, etc.). Provide a rationale as to why you selected the CQI method. Include details about how the procedures will be used in the never event scenario by applying the steps to the event. 6. Create a process flow diagram (flowchart) to show the recommended process(es) or steps that must be followed to avoid this event in the future. Include the type(s) of intervention(s) needed to correct the problem (e.g., reducing human error, reducing procedural errors, etc.). How to Add a Flow Chart to a Slide in PowerPointLinks to an external site. How to Create a SmartArt graphic from scratchLinks to an external site. (if you prefer to do your own shapes) 7. Discuss how you will monitor, evaluate, and control the improvement plan. Include details regarding whether the results are sustainable over time. Include whether modifications are needed to maintain the improvement. Include details regarding avoiding drift (e.g., returning to old ways of doing things, which caused the event). The Never Event presentation must be 15 to 20 PowerPoint slides in length (not including title and references slides) and formatted according to APA Style