Imagine that you are the risk manager of an accountable care organization. Select one never event from the list on page 79 and describe how you would institute proactive monitoring for POAs. For this discussion:

• Describe how you would intervene when an HAC occurred.
• Identify departments or functional areas that would be involved in reporting to regulatory entities.
• Describe problem resolution.
• Describe how you would use the data from the lesson learned for organizational improvement.