1. 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

2. 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

3. 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

4. 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

5. 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.”

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

7. 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

8. 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.

9. 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.

10. 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

11. 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.)

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

13. 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

14. 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

15. 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

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

17. Disciplinary Decision Making
Outcome-Based
Rule Based
Risk Based 17

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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.

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

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