Does every episode of hypoglycemia have to be evaluated for DSPM.1 EP.3.a if it is or is not a performance measure?

All episodes of hypoglycemia have to be evaluated for root cause and causes need to be aggregated and analyzed for system issues. The "Topics" library available from our website offers an example of a framework for conducting a root cause analysis. However, this specific framework is not mandated as there are other root cause analysis tools available that may better meet the needs of the organization.  The following link will take you to our website where our tool may be downloaded:  Framework for Conducting a Root Cause Analysis and Action Plan