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

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

3. Risk Management Survey 3

4. 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

5. 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

6. 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

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

8. 2015 Survey Finding Results Florida State 8

9. 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 H041615 Day Reports6 9 H0408RM Program - Pt Grievance Analysis7 7 H0415Development Of Corrective Procedures8 7 H0417Sexual Misconduct9 7 H0402RM Program - Investigation & Analysis10 6 9

10. 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

11. Federal Top 10 Hospital Tag Summary for Calendar Year 2015 Health Tag TitleTopTotal A0395RN Supervision Of Nursing Care1 21 A2400Compliance With 489.242 17 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 Bylaws10 5 11

12. Hospital Code 15 Report Totals by Category of Injury for Calendar 2015 Category Quarter 1 -- 1/1/2015 to 3/31/2015 Quarter 2 -- 4/1/2015 to 6/30/2015 Quarter 3 -- 7/1/2015 to 9/30/2015 Quarter 4 -- 10/1/2015 to 12/31/2015 Death 31 3331 Fetal Death 53 22 Brain Damage 56 97 Spinal Damage 02 11 Surgical Procedure Performed on the Wrong Site 10 5 Surgical Procedure Performed on the Wrong Patient 31 11 Wrong Surgical Procedure Performed 32 20 Surgical Procedure Unrelated to the Patient's Diagnosis 2941 3137 Surgical Procedure to Remove Foreign Objects from a Surgical Procedure 2824 2821 Surgical Repair of Damage/Injury from a Planned Surgical Procedure 67 69 Outcome Other Description 00 00 12

13. Any Questions? 13

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

16. 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

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

18. The Process The Problem & The Whys?

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

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

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

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

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

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

25. 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

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

27. RCA Interactive Exercise 27

28. 28

29. AHCA Report Requirements Due April 1, 2016 by Midnight https://apps.ahca.myflorida.com/adverseincide ntreport/https://apps.ahca.myflorida.com/adverseincide ntreport/ 29

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

31. AHCA Florida Center for Health Information and Policy Analysis http://www.floridahealthfinder.gov/index.html Summary of Findings 31

32. AHCA Regulated Health Care Provider Resources http://ahca.myflorida.com/MCHQ/Licensee_Pr ovider_Resources.shtml Online Licensing, Submission and Reporting Hospitals Office of Risk Management and Patient Safety 32

33. AHCA Regulated Health Care Provider Resources Hospitals Office of Risk Management and Patient Safety Patricia.Vidal@ahca.myflorida.com User ID, Passwords Online Adverse Incident Reporting Florida Statutes 395.0197 http://www.leg.state.fl.us/statutes/index.cfm Hospital Licensing and Regulation 2015 Florida Statutes 33

34. AHCA Regulated Health Care Provider Resources Florida Administrative Codes- Hospital 59A-10, F.A.C. http://www.leg.state.fl.us/statutes/index.cfm Hospital Licensing and Regulation 2015 Florida Statutes 34

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

36. Resources http://www.fda.gov/Safety/MedWatch/default. htmhttp://www.fda.gov/Safety/MedWatch/default. htm https://apps.ahca.myflorida.com/adverseincide ntreport/https://apps.ahca.myflorida.com/adverseincide ntreport/ 36