Florida Society of Healthcare Risk Managers and Patient Safety Risk Management and Quality Symposium 2016

Agency for Health Care Administration Risk Management and Quality Update Patricia Kaczmarek, BHSc., MSHL, RN Survey and Certification Support Branch

Risk Management Survey 3

Risk Management Survey Process –Offsite Preparation Risk Management Survey Entrance Conference Materials Checklist –Entrance Risk Management Survey Entrance Conference Materials Checklist –Information Gathering –Decision Making /Analysis of Findings –Exit Conference –Post Survey Activities 4

Risk Management Process Important Considerations Initial /Entrance – Sets tone for survey Collaboration- Surveyors and Hospital Team Both parties need each other to complete the Survey Process Patient Safety Organization Patient Safety 5

Risk Management Process Important Considerations Patient Safety Organization- (PSO) Which Entity and When Patient Safety Work Product- (PSWP) Policy and Procedures Patient Safety Evaluation System-(PSES) PSWP data under the PSES 6

Risk Management Process Important Considerations Stroke Centers Hospital - Acquired Conditions Safety Incidents 7

2015 Survey Finding Results Florida State 8

Risk Management Top 10 Hospital Tag Summary for Calendar Year 2015 Health Tag TitleTopTotal H0412Incident Reporting System - Reports1 38 H0410RM Program - Incident Reporting System2 29 H0426Patient Safety Officer And Committee3 29 H0404Approp Measure - Education & Training4 21 H0411Incident Reporting System-Procedures/Training5 15 H Day Reports6 9 H0408RM Program - Pt Grievance Analysis7 7 H0415Development Of Corrective Procedures8 7 H0417Sexual Misconduct9 7 H0402RM Program - Investigation & Analysis10 6 9

State Top 10 Hospital Citation Summary for Calendar Year 2015 Health Tag TitleTopTotal H0412Incident Reporting System - Reports1 38 H0120Nursing Service - Care Process2 32 H0410Rm Prog - Incident Reporting System3 29 H0426Patient Safety Officer And Committee4 29 H0404Approp Measure - Education & Training5 21 H0029Patient Rights & Care - Add'L Policy/Procedure6 17 H0411Incident Reporting System-Procedures/Training7 15 H0119Nursing Service-Std Of Practice & Policy/Procedure8 14 HZ815Background Screening; Prohibited Offenses9 12 H0020Patient Rights & Care - Reassessment10

Federal Top 10 Hospital Tag Summary for Calendar Year 2015 Health Tag TitleTopTotal A0395RN Supervision Of Nursing Care1 21 A2400Compliance With A0749Infection Control Program3 15 A0396Nursing Care Plan4 12 A0405Administration Of Drugs5 11 A2409Appropriate Transfer6 11 A0392Staffing And Delivery Of Care7 8 A2406Medical Screening Exam8 8 A0263QAPI9 5 A0353Medical Staff Bylaws

Hospital Code 15 Report Totals by Category of Injury for Calendar 2015 Category Quarter /1/2015 to 3/31/2015 Quarter /1/2015 to 6/30/2015 Quarter /1/2015 to 9/30/2015 Quarter /1/2015 to 12/31/2015 Death Fetal Death Brain Damage Spinal Damage Surgical Procedure Performed on the Wrong Site 10 5 Surgical Procedure Performed on the Wrong Patient Wrong Surgical Procedure Performed Surgical Procedure Unrelated to the Patient's Diagnosis Surgical Procedure to Remove Foreign Objects from a Surgical Procedure Surgical Repair of Damage/Injury from a Planned Surgical Procedure Outcome Other Description

Any Questions? 13

Agency for Health Care Administration Risk Management and Quality Update Patricia Kaczmarek, BHSc., MSHL, RN AHCA Survey Certification and Support Branch

Agency for Health Care Administration Risk Management Root Cause Analysis Patricia Kaczmarek, BHSc., MSHL, RN Survey Certification and Support Branch Ann Rizzuto, RN Specialist, AHCA Field Office 9-10

Agency for Health Care Administration Root Cause Analysis Root Cause Analysis Toolkit

The Process The Problem & The Whys?

Historical Evaluation Date Time- Multiple times as related to the event Informational Source- Multiple What - RCA Why – Process Improvement Who - How - Meeting 19

Process Analysis Process Factors: –Human –Equipment –Environmental –Information Factors –Communication –Policy & Procedure/Practice 20

Process Interventions Time line Meetings – Who? Facts Interviews – Record of interview Questions- Formulate Discuss Next Steps- Responsibilities, goals, oversite Reportable or Non-reportable 21

Review Sentinel Event Tools? –SE Process- Share? –Potential event –Notifications –Designee 22

Review Sentinel Event Tools? –Designee- –Process Flow Risk /Liability SE Focused Review Medical Staff Review 23 RM Administration Directors, Managers

Risk / Liability Injury RM and QA- Determine Regulatory Impacts Interview Process- Potential Litigation Approach Patient and Family- Interview / Meeting Risk Manager- Ongoing involvement 24

SE Process - Focused Review RM and QA- Determine Reporting Obligations RCA Conducted- Comprehensive Action Plan- Peer Review Confidentiality Communication of the CAP- Administration, Medical Leadership Implementation of the CAP- Responsibility and oversight involvement Evaluate CAP Effectiveness- CAP Oversight and Designee Report 25

Medical Staff Process – Peer Review Medical Staff Involved- Refer for Peer Review Medical Staff Responsibility – Comprehensive Actions based on Findings and Investigations 26

RCA Interactive Exercise 27

28

AHCA Report Requirements Due April 1, 2016 by Midnight ntreport/ ntreport/ 29

30 Adverse Incident Annual Report Annual Risk Management Reports are due by midnight of April 1. User Login Enter User ID: * Enter Password: *

AHCA Florida Center for Health Information and Policy Analysis Summary of Findings 31

AHCA Regulated Health Care Provider Resources ovider_Resources.shtml Online Licensing, Submission and Reporting Hospitals Office of Risk Management and Patient Safety 32

AHCA Regulated Health Care Provider Resources Hospitals Office of Risk Management and Patient Safety User ID, Passwords Online Adverse Incident Reporting Florida Statutes Hospital Licensing and Regulation 2015 Florida Statutes 33

AHCA Regulated Health Care Provider Resources Florida Administrative Codes- Hospital 59A-10, F.A.C. Hospital Licensing and Regulation 2015 Florida Statutes 34

References Minnesota Department of Health (2015, December 8). Root Cause Analysis Toolkit. Retrieved from Minnesota Department of Health: Minnesota Department of Health 35

Resources htmhttp:// htm ntreport/ ntreport/ 36