1. “Breaking the Bottleneck - Case Management: Unplugged” Karen McGovern, College of Nurses of Ontario Angela Bates, College of Physicians & Surgeons of Ontario Claudia Skolnik, Ontario College of Pharmacists Moderator: Beth Davey, College of Physicians & Surgeons of Ontario 2006 Annual ConferenceAlexandria, Virginia Council on Licensure, Enforcement and Regulation Expect the Unexpected: Are We Clearly Prepared?

2. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Facing the Frontline Karen McGovern Manager, Investigations College of Nurses of Ontario

3. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Outline 1.Background 2.Executive Director Actions 3.ART: Risk Assessment Tool

4. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia 1. Background The College of Nurses of Ontario is the self-regulatory body for 140,000 nurses in Ontario, Canada. We receive approximately 1500- 2000 complaints, reports and inquiries each year.

5. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Intake Function Intake Team conducts inquiries of all reports received Aim is to collect sufficient information about the alleged conduct in order to make a recommendation to Executive Director (ED) for appropriate regulatory response ED has discretion to investigate when she has reasonable and probable grounds to believe nurse committed misconduct or incompetence

6. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia 2. Executive Director Actions Protection of the public must be: Efficient not every case requires a formal investigation must ensure that high risk matters receive full resources Effective want to know that member understands the applicable standards of practice and will practice safely in future can achieve same outcome without an investigation in some cases

7. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Executive Director Actions Three levels of Executive Director Action: a)Bank b)Investigate c)Invitation to Provide Assurances

8. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia (a) Bank The matter is not inherently serious and does not require a full investigation Notify nurse of report received and outline regulator’s expectations for practice in future Report retained on file – matter is not closed. Can be investigated if further matters are reported in the future

9. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia (b) Investigate Matter is inherently serious and would meet the threshold for referral to discipline hearing Nurse is notified; full investigation completed; screening committee determines outcome – may include referral to discipline or remedial action such as an undertaking to meet with a nurse expert

10. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia (c) Invitation to Provide Assurances Matter is inherently serious and mitigating circumstances are present (e.g. isolated incident; nurse admits) Nurse is informed of report; invited to meet with Executive Director to provide assurances of safe practice in the future Aims are: to articulate regulator concerns; for nurse to demonstrate understanding and recognition of issues and to commit to practicing in accordance with standards. May involve undertakings or monitoring If assurances are sufficient, matter is banked. If assurances are not sufficient, matter is investigated

11. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia 2. Risk Assessment Tool: ART ART provides assistance with the assessment of risk in matters reported to CNO; Helps to attain consistency, accuracy and timely response Based on a risk identification and management model Identifies the types of conduct and practice that CNO believes to be a risk to public safety and makes these factors transparent to stakeholders.

12. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia ART The values and norms of the nursing profession provide the framework: Professional Standards- Accountability, Continuing competence, Ethics, Knowledge, Knowledge application, Leadership, Relationships Ethics- Client choice, Client well-being, Privacy/confidentiality, Respect for life, Truthfulness, Maintaining commitments to clients, self, health team members, profession, quality practice settings

13. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia ART Types of conduct/ practice concerns that may be reported about a nurse are given pre-determined ratings, based upon degree of deviation from the norms and values The reported conduct/practice is then assessed using additional factors that may increase or diminish risk A numerical score is tabulated

14. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia ART Other factors considered: Is there a pattern of conduct/practice concerns? Does the nurse have a prior reports/complaints to CNO Does the conduct/practice concern constitute a violent act? Does the nurse have relevant experience or was this a new situation for the nurse? Did the conduct/practice result in significant harm? Could it have? Was the alleged act intentional or reckless? Does the nurse demonstrate accountability, reflection, insight and a willingness to remediate?

15. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Speaker Contact Information Karen McGovern, RN LLB College of Nurses of Ontario Toronto, Ontario, Canada (416) 928-3831 kmcgovern@cnomail.org www.cno.org

16. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Cracking Cases Angela Bates Manager, Committee Support and Compliance Monitoring College of Physicians & Surgeons of Ontario

17. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Investigations - Overview Investigative Processes Investigator Qualifications Case Streaming Benchmarks, Reports & Audits

18. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Challenges and Strategies Protocol for identifying categories Investigative Processes –Clinical care vs. incompetence vs. professional misconduct vs. member incapacity: case management implications

19. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Investigative Processes Consider different –statutory requirements –fairness requirements –priorities = case management implications

20. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Investigator Qualifications –Generalist vs. specialist –Education vs. experience –Other background –Interview and testing

21. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Investigator Qualifications Generalist vs. specialist –E.g., individual with education/ experience over broad areas vs. individual with specific, deep knowledge in one area

22. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Investigator Qualifications Generalist: –Pros: Can manage multiple types of investigative processes: case management implications Versatility: budget implications

23. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Investigator Qualifications Generalist: –Cons: Quality of investigative work in specialized matters Depth of knowledge; e.g., misconduct and incapacity investigations very different

24. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Investigator Qualifications Specialist: e.g., MSW, RN –Pros: With appropriate experience, deep understanding of area; e.g., mental health Permits case streaming by nature of issue

25. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Investigator Qualifications Specialist: –Cons: Less cross-training: budget and case management implications Unable to see forest for trees: missing important indicators, too focused

26. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Investigator Qualifications Education vs. Experience: –Diploma vs. degree or postgraduate –Experience: younger, more flexible and less experienced?; older, more experienced? importance of maturity, depth of experience

27. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Investigator Qualifications Other background: –Mediation, conflict resolution skills –Analytical skills –Language skills –Time management/office/ administrative skills

28. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Investigator Qualifications Interview and testing –Situational questions –Maturity –Analytical skills –Detail orientation

29. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Case Streaming –Prioritizing investigations –Generalist vs. specialist –Investigation vs. resolution

30. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Case Streaming Prioritizing investigations: –“Triage” –“Critical” vs. “High Profile” vs. “Regular” –Resource implications –Timeline implications

31. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Case Streaming Prioritizing investigations: –Pros: Important matters have more attention and resources focused on them; move more quickly; public interest protected

32. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Team Structure (CPSO) Generalist vs Specialist Shared investigations Delegation of investigation steps Communication & consistency Template correspondence and filing

33. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Case Streaming Prioritizing investigations: –Cons: Tendency to “back-burner” less urgent matters Need to balance less critical and more critical; efficiency and thoroughness

34. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Case Streaming Resource implications: –“Triaging” matters: need resources to devote to critical matters and still keep more routine issues moving –Investigators, support staff, screening committees –Need to agree on streaming criteria

35. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Case Streaming Timeline implications: –Different benchmarks for prioritized matters? –Challenge: meet benchmarks on all types of matters

36. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Measurement Tools Benchmarks, Reports & Audits –Realistic timeline expectations –Need to differentiate critical and high profile matters: different benchmarks –System reports –Audits: file audits, decision audits

37. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Benchmarks, Reports & Audits Realistic timeline expectations: –Legislation may dictate timelines; e.g., 120 days for public complaints in Ontario –Staffing, resource implications –Importance of time/case management training and skills for investigators

38. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Benchmarks, Reports & Audits “Critical” vs. “High Profile” –E.g., 180 days vs. 240 days (benchmarks should measure from information received date, not just date assigned to investigator)

39. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Benchmarks, Reports & Audits Reports: –Online administrative tracking systems: capacity to produce regular reports, batch requests and responses to individual queries

40. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Benchmarks, Reports & Audits Reports: –Need for regular production of reports –Benchmarks, high profile cases; individual investigator, team workloads, timelines –Need for regular review

41. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Benchmarks, Reports & Audits Audits: –Quality assurance mechanism –Purpose: Educational; process reform; should not target performance management

42. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Benchmarks, Reports & Audits Audits: –Regularly audit sample of closed investigative files by disinterested staff or auditor –Audit for statutory requirements; adherence to policies/procedures; timelines; file organization; etc.

43. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Speaker Contact Information Angela Bates College of Physicians and Surgeons of Ontario 80 College Street Toronto, Ontario, Canada M5G 2E2 Tel. 416-967-2630/Fax 416-967-2653 abates@cpso.on.ca http://www.cpso.on.ca/

44. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Busting Discipline Backlogs Claudia Skolnik Manager, Investigations & Resolutions Ontario College of Pharmacists

45. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Overview What is a backlog? Understanding how it occurred? Problem analysis – where is the problem? What are the issues? Opportunities for process improvement

46. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Fundamental Considerations Public Safety Public Accountability Membership Accountability Strategic Direction Interim Shift in Prosecutorial Philosophy Openness

47. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Strategy for Gaining Control Review and synopsize cases Group cases in categories & themes Combine multiple referrals about same member –Visible Chart Develop and obtain strategic direction re prioritizing of categories

48. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Assess Post Referral Information Consider interim shift in prosecutorial philosophy Update post referral information about the member –Compliance –Death –Resignation

49. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Root Cause Analysis Internal staffing Only one prosecutor (general counsel) Absence of case management system Low expectations of timeliness Limited alternative options Absence of membership advocacy

50. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Alternative Resolution Stream Expand remediation options Identify alternative suitable venues for resolution –Compliance inspections –Incapacity process Obtain authority and parameters for an accountable alternative resolution model

51. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Business Plan Develop and present the business plan Outline priorities, prosecutorial direction and time lines Identify the human resourcing needs Obtain approval for new resourcing model

52. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Building Your Prosecutions Team Identify human resourcing model –Expand internal staffing –Recruit external prosecutors Build a prosecution team Develop expertise and efficiencies –Group cases and themes –Consider special skills and background

53. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Discipline Case Management Strategic assignment of group cases Set strict timelines for stages and deadlines and monitor Develop a pre-hearing process –Negotiating ASFs and JSPs in advance –Time managed dates for hearings Track legal fees per case –Assessment stage –Pre hearing conference stage –Hearing stage

54. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Discipline Committee Administration Develop Rules of Procedure to increase efficiencies –Pre-hearing motion (1 member) –Conference calls and correspondence Get commitment from the tribunal for the volume (request, persuade and beg) Secure set dates for hearings (synchronizing schedules in advance)

55. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Discipline Committee Administration Schedule multiple hearing day –2-3 uncontested hearings –Cold lunches! Administrative support for decision writing –Soft copy of ASF and JSPs Same day decision administration

56. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Legal Considerations Delay and Prejudice Limitation of Prosecutorial Discretion –Executive Committee Referrals –Complaints Committee Referrals Conflicts of Discipline Committee members

57. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Challenges Prosecution based on antiquated philosophies – backlash Glut of cases – misplaced impression of zealous punitive approach

58. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Opportunities!!! Cost efficiencies –prosecutions –hearings Establishment of consistent precedents Development of prosecutor expertise Establishment of sound case management and delay prevention techniques Development of alternative resolution methods for ongoing practice

59. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Key Components for Success Clear strategic priority Authority and flexibility to recruit team Securing financial resources Accountable communication strategy

60. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia Speaker Contact Information Speaker NameClaudia Skolnik Organization Ontario College of Pharmacists Address 483 Huron Street, Toronto, Ontario, Canada M5R 2R4 Phone, Fax416 847 8238 E-mailcskolnik@ocpinfo.com Websitewww.ocpinfo.com