Developing an Effective Correction Action Plan - DoctorsManagement Developing an Effective Correction Action Plan - DoctorsManagement

Developing an Effective Correction Action Plan (CAP)


We’re human, we make mistakes but it’s how we respond to our mistakes that defines our character and commitment as healthcare compliance professionals.

When a medical facility has a Corrective Action Plan (CAPS), it serves as a critical component to the message that we are committed to doing the right thing. It demonstrates that our compliance plan is a living, dynamic document that’s ever adjusting and growing with the organization. Many compliance professionals are quick to self-disclose when an error is identified, but self-disclosure is not always warranted. Oftentimes, things we make mistakes on don’t lead to undeserved remunerations. They might be a simple breakdown in a process that needs to be better defined or clarified.

Before making a decision about self-disclosure, you should speak with your health care attorney to determine the best course of action, and regardless of the final determination you still need to develop a CAP.

There are (5) basic aspects of a CAP:

  1. Issue/ Problem Definition- Identify the potential problem and provide a lay explanation of the problem (e.g. Cloning)
  2. Root Cause- Identify what led to the potential problem (e.g. The ease of cutting and pasting or carry forward within an EMR)
  3. Action Steps- Identify the steps taken to correct or reverse the potential problem (e.g. Training and Education for all providers documenting within the EMR)
  4. Improvement Benchmark(s) and Timeframes- How you will monitor the situation going forward to ensure compliance (e.g. Re-review of provider documentation within 30-days after training and education)
  5. Certification- The compliance officer or responsible party for ensuring compliance signs off on the CAP

Following this outline will help ensure you properly build a process of improvement through the development of a CAP and that results in a level of compliance that helps to keep the governmental investors at bay. For a sample CAP you can use to create your own click here.

Sean M. Weiss, Partner, VP/Chief Compliance Officer of DoctorsManagement’s Department of Audit and Regulatory Compliance (ARC). Sean is not an attorney and this information does not serve as legal advice or substitution for legal counsel. If your organization is in need of compliance assistance (Plan and Policy Development, Restructuring, or Third Party Compliance Officer Services) you can reach Sean at or by calling (800) 635-4040.