Involving Stakeholders in TERCAP Implementation 2008 TERCAP FORUM April 7, 2008 Charlotte F. Beason, Ed.D., RN Executive Director, Kentucky Board of Nursing Jan Ridder, MA, RN CHE Past Member, Kentucky Board of Nursing

Involving Stakeholders in TERCAP Implementation Why Kentucky Implemented TERCAP Strong Commitment to Just Culture Increased number of complaints in which system issues played a part Tool will analyze root cause of practice breakdown Opportunity for data analysis on a national or state level

Involving Stakeholders in TERCAP Implementation Stakeholders have knowledge and expertise needed to create a sustainable/realistic policy Buy-in by stakeholders is critical to the successful implementation of any Board policy

Involving Stakeholders in TERCAP Implementation Kentucky Implementation Process Task Force convened (members nominated by stakeholder organizations) Nurses from each level of health care: executive to staff nurse Staff development/risk managers long term, acute care and community facilities

Involving Stakeholders in TERCAP Implementation Implementation Process continued Task: “Make recommendations regarding how KBN should collaborate with healthcare facilities when identified practice errors and violations of the KY Nursing Laws are seen to result from both system and individual deficiencies.”

Involving Stakeholders in TERCAP Implementation Implementation Process continued Introduce TERCAP instrument Present case studies and discuss issues Formulate Recommendations and forward to Board

Involving Stakeholders in TERCAP Implementation Task Force Recommendations Endorsed the use of TERCAP by KBN Requested that NCSBN modify one question on instrument Requested online access to the TERCAP instrument for use by facilities

Involving Stakeholders in TERCAP Implementation Task Force Recommendation If after investigation, the facts reveal that the complaint could result in part from a facility systems or process issue the case will be presented to the Credentials Review Panel for direction. The Panel may direct staff action to file the complaint away which resolves the case or issue a Letter of Concern to the nurse and/or issue a Letter of Concern to the facility and/or direct disciplinary action.

Involving Stakeholders in TERCAP Implementation FACILITY LETTER OF CONCERN The Letter of Concern will be sent to the Chief Nursing Officer along with the Chief Executive Officer of the facility and will detail the issue of concern on behalf of the Board of Nursing. The letter will be maintained in the nurse’s investigative file. The facility will be asked to file a response to the Board of Nursing. The response from the facility will be placed in the investigative file.

Involving Stakeholders in TERCAP Implementation Communication Strategies Letter to all Nurse Executives in the state Articles in newsletter/web site info Presentations at healthcare organizations Incorporated into Board sponsored Leadership Program (presented 4-6x/yr) Meetings scheduled by request

Involving Stakeholders in TERCAP Implementation KBN Referral Policy Continues If the Board finds that another entity may retain jurisdiction over the individual nurse reported or the case involves more than one discipline, referrals may be made to the appropriate agency (Dept of Health, Medical, Pharmacy, Dental Boards, etc.) www.kbn.ky.gov 502-429-3300

Kathy Scott Joey Ridenour It Takes a Village Kathy Scott Joey Ridenour 12

Four Objectives Describe the CNO’s difficulties in determining when & what to report Describe Evolution of Tri-Partnership & Knowledge Sharing Share Refinement of Tools Developed & Concrete Processes Learn From Mistakes & Next Steps

What We Know Today Adverse-event reporting is dependent upon the willingness of people to report High-Reliability Organizations are dependent upon collective learning from mistakes or close calls Overall system safety is NOT improved by disciplining employees. The State Board of Nursing (SBON) role is to protect the public. 14

Health System’s Concerns When is reporting to the SBON appropriate for a particular situation? How do we differentiate between punishing & reporting? What does it mean to be “fair and just”? 15

Discipline System Theory Human Error Negligent Conduct Reckless Conduct Knowing Violations 16

Disciplinary Decision Making Outcome-Based Rule Based Risk Based 17

Health System & SBON Partnership Objectives Foster open communication & improve sharing real-time information through use of TERCAP Increase knowledge of patterns & trends related to practice breakdown resulting in organizational learning Better understand reportable events, contributing factors & SBON actions 18

Three Factors Related to Progress Over emphasizing the forest & little attention to the trees Concepts aimed at Board Investigators & Executive Directors rather than where critical organizational work is done Protocols & tools were lacking

Village Blueprint-Built from the Ground Up Learning occurs in healthcare delivery, nursing administration & board with shared and overlapping work activities Nurse Executive Internship Role Developed & Approved by Board 6 months duration Nurse Executive signs confidentiality agreement Attend three board meetings, reviews approximately 300 investigative/hearing reports for each board meeting for total 900 cases

Building Blocks of Village Each block has own discreet subcomponents, vital to the whole Blocks are independent & measured separately Different mechanisms at work in each building block & improvement in each is likely Slice & dice data

Block 1: Support & Openness to new ideas (Garvin/Edmondson/Gino) Chief Nursing Officers assure TERCAP is utilized Associate Director Investigations/Compliance embeds TERCAP tool into investigative processes Associate Director Education & Evidenced Based Regulation assists in process Chief Nursing Officers assure TERCAP is utilized in a standardized investigative process; information completed on form & submitted with letter to SBON; data entered into data base Associate Director Investigations/Compliance embeds TERCAP tool into investigative processes & fosters use of information in ongoing investigation Associate Director Education & Evidenced Based Regulation assists in education investigative staff, revision of investigative tools & facilitates staff competency in using TERCAP & data entry

Block 2: Learning Processes & Practices 1.) Health Delivery System a. educated nurse executives on TERCAP concepts & submission of data on tool b. developed policies regarding information submitted to board c. developed data base to capture tool data d. will analyze system data 2.) SBON: a. educated investigative staff on TERCAP concepts/tool b. TERCAP data collection through revised Investigative questionnaire c. Address concerns regarding changes

Block 3: Leadership Alone is Insufficient We are far less interested in people having the right answers than that they think about the issues the right way.

Investigative Case analysis using TERCAP Before & After TERCAP Investigative Case analysis using TERCAP

Summary & Next Steps It Take A Village Kathy Scott Joey Ridenour 26