1. Page 1 County of Los Angeles Corrective Action Plan Program Enhancements John Sterritt CEO Risk Management

2. Page 2 Agenda What is a Corrective Action Plan What is a Summary Corrective Action Plan CAP/SCAP Confidentiality

3. Page 3 CAP/SCAP Program Effective May 18, 1999, the Board of Supervisors (Board) required the completion of a comprehensive Corrective Action Plan (CAP) for all liability settlements over $100,000. Effective November 1, 2007, the Board required a Summary Corrective Action Plan (SCAP) for liability settlements in excess of $20,000 ($100,000 Medical Malpractice).

4. Page 4 The CAP/SCAP Process: Researching the cause of loss event Developing a CAP/SCAP Assessing the CAP/SCAP’s effectiveness Implementing the CAP/SCAP CAP/SCAP Process

5. Page 5 The County of Los Angeles CAP/SCAP Process 1.Initial supervisor investigation occurs 2.Initial remedial action (hazard abatement) occurs 3.Board-required CAP/SCAP initiated 4.Claim and/or lawsuit filed against the County 5.Claim/lawsuit investigated and adjusted to determine liability and exposure 6.Claim settlement proposed and accepted in excess of $20,000 (>$100,000 for medical malpractice) 7.SCAP is submitted with settlement documentation to the County of Los Angeles Claims Board (Claims Board); if settlement is over $100,000, CAP also required 8.If settlement is over $100,000, the SCAP, CAP and, Claims Board documents are forwarded to the Board 9.Board approves settlement and reviews CAP/SCAP 10.CAP/SCAP implemented and evaluated for effectiveness/closure Following the Loss Event:

6. Page 6 What is a Corrective Action Plan A CAP is a collection of corrective actions to mitigate or eliminate the causes of the loss event. The plan includes: Specific corrective actions Who is responsible for the entire plan Criteria to measure plan effectiveness Although no specific CAP form is mandated, CEO has a recommended form that all departments can use.

7. Page 7 What is a Summary Corrective Action Plan A Summary Corrective Action Plan (SCAP) provides the Board an executive summary of the corrective actions taken by a department and is required for all liability settlements over $20,000 (>$100,000 for medical malpractice). Specific form is mandatory.

8. Page 8 What is a Summary Corrective Action Plan A SCAP is intended to be read in conjunction with the associated Case Summary prepared by the County Counsel’s Office. The Case Summary states the salient facts of a case, and the SCAP informs the public of the corrective actions taken by a department. All SCAPs and all Case Summaries are public documents – some are confidential. SCAPs and Case Summaries are not prepared for the following two types of settlements: Litigation involving multiple parties, where the settlement is with some but not all of the plaintiffs Requests to make statutory settlement offers (California Code of Civil Procedures Section 998 and Federal Rule of Civil Procedure Rule 68 offers)

9. Page 9 What is a Summary Corrective Action Plan Effective November 1, 2007 1. Purpose Executive Summary of corrective actions taken by a department Required for claim settlements in excess of $20,000 ($100,000 for Medical Malpractice) Included in Claims Board settlement documents 2. Confidentiality All SCAPs are public documents, none are confidential If there is a question as to confidentiality, please consult County Counsel

10. Page 10 What is a Summary Corrective Action Plan Document that outlines the following: 1.Root Causes 2.Corrective Action Steps 3.Applicability to Other Departments

11. Page 11 The intent of this form is to assist departments in writing a corrective action plan summary for attachment to the settlement documents developed for the Board of Supervisors and/or the County of Los Angeles Claims Board. The summary should be a specific overview of the claims/lawsuits’ identified root causes and corrective actions (status, time frame, and responsible party). This summary does not replace the Corrective Action Plan form. If there is a question related to confidentiality, please consult County Counsel. What is a Summary Corrective Action Plan Form Instructions

12. Page 12 Date of incident/event: Briefly provide a description of the incident/event: (See County Counsel Case Summary) Section One: Event description What is a Summary Corrective Action Plan

13. Page 13 Briefly describe the root cause of the claim/lawsuit: Briefly describe recommended corrective actions: (Include each corrective action, due date, responsible party, and any disciplinary actions if appropriate) What is a Summary Corrective Action Plan Section Two: Root Cause and CAP Steps

14. Page 14 What is a Summary Corrective Action Plan State if the corrective actions are applicable to only your department or other County departments: (If unsure, please contact the Chief Executive Office Risk Management Branch for assistance) Potentially has County-wide implications. Potentially has implications to other departments (i.e., all human services, all safety departments, or one or more other departments). Does not appear to have County-wide or other department implications. Section Three: CAP/SCAP Applicability

15. Page 15 Signature: (Risk Management Coordinator) Signature: (Department Head) Section Four: Review and Approval What is a Summary Corrective Action Plan

16. Page 16 County CAP Data Table 1. Number of CAPs for Tort Liability Claims by Fiscal Year (FY)

17. Page 17 CEO CAP/SCAP Programs The CEO offers a number of CAP/SCAP training opportunities. Since 2005, the CEO has trained over 500 County employees in the development and implementation of CAP/SCAPs. The CEO published the Corrective Action Plan User’s Guide to enhance development of CAP/SCAPs within the County. In addition, CEO Loss Control and Prevention prepares Departmental Needs Assessments to assist in the identification of CAP/SCAP issues.

18. Page 18 CAP Confidentiality CAPs are generally not confidential and will be released to the public Exceptions – the following CAPs are marked confidential and are not released to the public: DHS will continue to mark medical malpractice CAPs confidential Employment related CAPs will continue to be marked confidential Before marking other CAPs confidential, a department needs to discuss the basis for the confidentiality with County Counsel CAPs will only be marked confidential when there is a specific statutory basis for the confidentiality CAPs are not to be marked confidential based on Attorney-Client Communication or Attorney Work Product

19. Page 19 SCAP Confidentiality All SCAPs and all Case Summaries are public documents – some are confidential. SCAPs and Case Summaries are not prepared for the following two types of settlements: Litigation involving multiple parties, where the settlement is with some but not all of the plaintiffs Requests to make statutory settlement offers (California Code of Civil Procedures Section 998 and Federal Rule of Civil Procedure Rule 68 offers) If there is a question as to confidentiality, please consult County Counsel.

20. Page 20 Questions?