SCAP/CAP - LA County

SCAP/CAPTHISMATERIALISSUBJECTTOTHEATTORNEY-CLIENTAND/ORATTORNEYWORKPRODUCTPRIVILEGES.

UNAUTHORIZED DISTRIBUTIONORDISCLOSUREOFTHEINFORMATIONISSTRICTLYPROHIBITED.

WhatisaCAP?A CAP is a Corrective Action Plan where one or morecorrection action steps are identified and placed in aformal document in order to correct aproblem/incidentwhich has occurred.

THISMATERIALISSUBJECTTOTHEATTORNEY-CLIENTAND/ORATTORNEYWORKPRODUCTPRIVILEGES.UNAUTHORIZED DISTRIBUTIONORDISCLOSUREOFTHEINFORMATIONISSTRICTLYPROHIBITED.

WhenshouldaCAPbewritten?

NOW!ShouldyouwaittowriteaCAPuntilthecaseissettled?

WhatisaSCAP?� A SCAP is a Summary Corrective Action Planwhich is a public document.

� Should namesof individuals be listed in a SCAP?

ConfidentialityAreSCAPs/CAPsconfidential?

WhenisaSCAP/CAPMandatory?� The Board of Supervisors (BOS), ordered the creationof a program to develop, implement, and managespecific Corrective Action Plans (CAPs) and SummaryCorrective Action Plans (SCAPs) for tort liabilitysettlements that result in settlements more than$100,000. Medical Malpractice cases are onlyrequired to draft SCAPs/CAPs that result insettlements formore than $100,000.

Whatisthedifferencebetweenafactorforsettlementandtherootcause?

� Thefactorforsettlementisalegalconceptwhereastherootcauseiswhytheincidentoccurred.

BenefitandImportance� Preventrecurrence� ProvidepreventivemeasuresonotheraspectsofCountybusinessprocesses

� Satisfylegalorregulatoryrequirementsforclaimsandlitigation

� Builddepartmentalawarenessandcommunicatebestpractices

EventTimelineImmediateCause Loss

RootCause ControlUndesiredEvent

Loss� Vehicleisdamagedbeyondrepair,bodilydamagetobothparties

� Personlosesincome,suffersemotionaldistress,andlosestheabilitytowork

� Discrimination,sexualharassment,retaliation,resultinginlossmoraleandlossdollars

� Badpublicity,publicscrutiny,criminalcharges,andlossofproductivity

UndesiredEvent� Vehiclerear-endingthevehicleinfrontofthem� Personslipsandfalls,impactingtheirhiponthefloor� Persondoesnotseethestep,falls,andhitstheirheadonthefloor

� Ahostileenvironmentdevelopswithinagroupofemployees

� Anemployee’saccommodationisdelayed� Aninspectorharassesarestaurantownerandasksforfavorsinreturnforgoodratings

Hazards� Leakingbrakelines� Wetfloor� Unevensurfacesandunmarkedsteps� Inadequatesupervision� Inadequatesubjectmattertraining� Employeemisconduct

ImmediateCause� Lossofbrakefluidandnopressureinthebrakelines� Inattentiontostepsorwetsurfaces� Foullanguageandderogatorycommentsmadetoco-workers

� Anemployeehaswaitedtwoyearwithoutaresponsetotheirreasonableaccommodationrequest

� Inspectorabusingtheirauthorityforpassing/failingtherestaurantwithinCOLAjurisdiction

RootCause� Mechanicsdonothaveaformallistofitemstocheckonvehicles

� Restroomsinkleakingforaweek,noreportingmechanismorinspections

� Awkwardpathsofegressandnodirectionalguidance� Supervisornottrainedorabletodisciplineemployees� Notthefirsttimethesupervisorknewaboutemployeemisconductandnothingwasdoneaboutit

CorrectiveActions� Vehiclechecklistisdevelopedformechanics� Restroomattendantsdoanhourlycheckonoperations� Redesignpathofegresswithdirectionalguidance� EachsupervisoronprobationgoesthroughsupervisoracademyandpoliciesinHRareenforced

� Aquestionnaireisgiventomembersofthepublicontheconductofinspectors

InvestigationTips� Handleemergencies� Securethescene� Gatherphysicalevidence� Gatherintelligence� Reviewpolicies,procedures,regulationsandguidelines

� Reviewexistingrecords� Seekinformationfromdepartmentsubjectmatterexperts

RootCauseDetermination5WhyApproach

1. Writeouttheproblem2. Ask“Whytheproblemhappened”3. Answereach“why”question4. Repeatstep2untilarootcauseisfound

5WhyApproachExampleProblem: TheWashingtonMonumentwasdisintegrating.

Why?UseofharshchemicalsWhy?TocleanpigeondroppingsWhysomanypigeons?TheyeatspidersandtherearealotofspidersatmonumentWhysomanyspiders?TheyeatgnatsandlotsofgnatsatmonumentWhysomanygnats?Theyareattractedtothelightatdusk

Solution:

Turnonthelightsatalatertime,whichdoesnotattractthegnatsatdusk,whichminimizestheamountofspidersduetoalackofafoodsource,whichminimizestheamountofpigeonandtheirdroppingresultinginaloweramountofharshchemicalsbeingused.Donotlimityouranalysisatthispoint.Thereisnolimittotheamountofquestions.Ifthisdoesnotwork,repeattheprocess.

RootCauseDetermination

CausalFactorsProcess/System

• Policy• Procedure• Lackofanefficienttrainingprogram

Personnel

• Actionsofpeople

• Actuponorfailtoactupon

Equipment

• Equipmentfailure

Property

• Damageordefectsinstructure

• Poorlighting• Stairs• Countyroad• Inadequatesecurity

CausalFactorExamplesProblem: TheWashingtonMonumentwasdisintegrating.

Process/System

• Nopolicyorproceduretodoperiodicinspectionofthemonumentfordamages

Personnel

• Employeesdidnotfollowinstructionsontheapplicationoftheharshchemicalsperpolicy

Equipment

• Applicationsprayhadafaultynozzleadministratingmorechemicals,thennecessary

Property

• Monumentlocationormaterialwasnotevaluatedforenvironmentalconditions

• N/A

CAPCASESTUDIES

� AutomobileLiability

� GeneralLiability

� EmploymentPracticesLiability

WHONEEDSWHAT?– CAPSTAKEHOLDERSWhatisRMIGlookingforinaSCAP/CAP?

RMIG will review the SCAP/CAP to ensure thatappropriate corrective actions have been taken and arerealistic, obtainable, goals which will not only solve theproblem but can be undertaken without an undueburden. Discipline, training, and system-wide correctiveactions are some of the items RMIG looks for whenreviewing a SCAP/CAP.

WhathappenstoaSCAP/CAPonceithasbeenapprovedbyRMIG?

Once approved, RMIG will send the signed SCAP back tothe Department who is required to send it to CountyCounsel. At this point County Counsel will schedule theClaims Board meeting as well as finalize their ClaimsBoardmemo.

COUNTYCOUNSELWhatisCountyCounsel’srolewithaCAP?� Once a SCAP/CAP has been drafted it is recommended the departmentsubmit to County Counsel to see if they have comments, after which thedepartmentwill send the SCAP/CAP to RMIG for approval.

� Once approved, RMIG will send the signed SCAP back to the Departmentwho is required to send it to County Counsel. At this point County Counselwill schedule the Claims Board meeting as well as finalize their ClaimsBoardmemo.

� It is always a good practice to checkwith County Counsel before finalizingthe SCAP/CAP to ensure that the Claims Board memo and the SCAP/CAPwork harmoniously togetherand are not contradictory to one another.

� Corrective actions should be taken as soon as possible after an incidentoccurs. County Counsel may not want or advise the actual CAP documentbe drafted at that time for liability purposes but this does not mean thatcorrective actions shouldnot be done!!!!!!!!

CLAIMS BOARDWhat is the Claims Board?� Cases involving settlements between $20,000 and $100,000 require theapproval of the County Claims Board. In the Claims Board meetings,representatives from departments, County Counsel, and outside counselpresent justifications for the proposed settlement amount and reviewcorrective action steps designed to prevent recurrences. For claims withsettlement amounts greater than $100,000, the Claims Board refers suchsettlements, with a recommendation, to the Board of supervisors for finalaction. The Claims Board has three (3) appointed members from the ChiefExecutive Office, County Counsel, and Auditor-Controller. The County RiskManager is the CEO member of the Claims Board, but the Loss Control andPrevention Manager, Operations Manager, and Risk Management InspectorGeneral are also actively engaged in reviewing and evaluating settlements.

WhatisaClustermeeting?� If a claim is over a $100,000 then this case and CAPwill go to the appropriate Cluster meeting whichinvolves in-depth discussions of CAPs and case facts,and at which Board Deputies, departments, CountyCounsel, and CEO attend.

� The purpose of these meetings is to brief the BoardDeputies on all relevant information so they can brieftheir Supervisors before final Board approval issought for a case.

BOARDDEPUTIES,DEPARTMENTSANDOUTSIDECOUNSEL

BOARDOFSUPERVISORSWhendoesmyCAPgototheBoardofSupervisors?� For claims with settlement amounts greater than $100,000, theClaims Board refers such settlements, with a recommendation, to theBoard of Supervisors for final action. At that time the BOS will thenapprove or deny the final settlement and CAP.

COUNTYWIDEAPPLICABILITYApplicabilityNoticesandwhattheycanbeusedfor.

� As part of best practices to prevent similar losses from occurring in thesame department, or in a different department with similar exposures,RMIG both publishes and presents Applicability Notices on a quarterlybasis. The Applicability Notices are summary level documents thatdescribe the incident, the root cause analysis of why it occurred, andthe CAP steps for correcting the root cause(s) and preventing a repeatincident. Presentations are held at the Risk Management Coordinatorsquarterly meetings and notices are published on the CEO/RMBwebsite.

CaseStudyEmploymentCountywideCAP� The development of Countywide CAPs involved collaboration betweenCEO/RMIG, County Counsel, Human Resources (DHR), Auditor-Controller, and CEO.

� Specifically, for the Fair Labor Standards Act claim, a mandatorytraining session was developed and implemented for all Countysupervisors andmanagers.

Countywide CAPS� In response to the settlement of two claims with far-reachingimpact in the areas of employment practices and the Fair LaborStandards Act, the Board of Supervisors asked CEO to develop aCountywide CAP process.

� Under the direction of the Board of Supervisors, and in concertwith DHR and County Counsel, CEO/RMB created the firstCountywide Corrective Action Plan documents. An extension ofdepartment-specific Corrective Action Plans, the CountywideCorrective Action Plans address claims and exposures withCountywide impact, and provide specific guidance to alldepartments on identifying and preventing similar claims andexposures in their respective units.

Claims,Incidents,RecommendedRemedialActions(RRAs)

SCAPsandCAPs

CountywideCorrectiveActions

CONSULTATIONYes,wemakehousecallstohelpwithallyourSCAP/CAPneeds!

� Ifyouneedhelpjustgiveusacallandwecanwalkyouthroughtheentireprocess.Wehaveatrainingmodulewecanputonforyourunit,andwecanalsoassistwithdraftingandreviewofindividualCAPs.

ResourcesRiskManagementInspectorGeneralRMIG@ceo.lacounty.govhttp://riskmanagement.mylacounty.info/rmig.asp(213)738-2194

CEORiskManagementBranchIntranetSite:http://riskmanagement.mylacounty.info

LossControlandPreventionhttp://riskmanagement.mylacounty.info/lcp_resource.asp

QUESTIONS?Thankyouforyoursupport!

SCAP/CAP - LA County

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