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Is the system alert to under-reporting?]= Client Protection Issues&%CMS DOJ Class Action LitigationZ&(A Systemic Approach $0uPolicies & Procedures Data Collection & Analysis Cross Organization Review Monitoring & Evaluation Mortality Review (u}vU8Rights vs. Risk &00 A goal of any Risk Management system is to address the challenge of balancing the responsibility to keep people safe with the goal of promoting independence and self-determination. <$$lE Application 06Leadership Systematic Approach Outcome EffectivenessH 7$e?Policies & ProceduresDAbuse & Neglect Risk Management Incident Reporting Informed Consent .E}C   VPerson Centered Planning Team Participation Family-Guardian Involvement Staff TrainingW}W fC+Data Collection, Incident Review & Analysis,,(kData collection Reporting Accuracy verification Data analysis (what, when, by whom) Data vs. Information Dj}}kgDProcedural Application g High Risk Individuals Assessment IDT Address Tracking Aggregate Analysis Causal Analysis &'$(&$!$0($(* Cause Analysis2B <@The most basic reason(s) for an undesirable condition or problemAA Purposes of Cause Analysis$( Traditional or Cause Analysis([Traditional Approach What happened? Who was responsible? What are we going to do to them?N8z G }Cause Analysis Answers WHY Contributing factors? Were barriers present? How could it have been prevented?XZnzZ n>2Cause Analysis Tools>Brainstorming Flowcharting Trending Cause Effect . . . . . .     $ $ $  $  Cross-Organizational Review &(Communicate & Coordinate Incident & Data Review Assimilate & Analyze Data Monitor & Track Systemic Consideration & Recommendations 6xY;+Monitoring & Evaluation (Assuring Outcomes)4,(0(lDid you do it? Did it work? Are others affected? What is the long-term impact? What are systems needs? ,mnQ60Mortality Review[Positive Aspects of Care Areas of Concern [ To learn things that will benefit the living]j0+0(3'"System Response0\Identification and Prevention Assessment and Planning Training and Support System Over-sight]]$mFA New Vision of Risk Management P Denise Micheletti, M.S., R.N. 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'2~+D=' = @B +!0 VNp(  X  C @   N  S @ 0   Broad definition HISTORY, COMMUNICATION CHANNELS, ORG. HEALTH MACRO CONCEPT (not reactive, not clinical cover-up) how is org philosophy demonstrated? values communicated? what language being used are stakeholders empowered? families? behaviors of admin & staff Is org person centered? how org responds to incidents is measure of health of organiz (knowing untoward things to happen, & having plan to deal w/ in advance) determines future for org & individuals being served-MAKING DIFFICULT DECISIONS - ELIMINATE USE OF RESTRICTIVE PROGRAMS BY ____; DECREASE USE OF PSY MEDS; ELIMINATE USE OF POLY-PHARMACY. decisions with Cross discipline; cross organizational, intra-organizational Quest for Quality must exist throughout all levels Be alert for consumer centeredness; how are consumers talked to/about, dressed, Not clinical cover-up (initial response always to Move, Increase Medications, Increase use of Restraints..) w/o looking as "root cause" H  0޽h ? 3380___PPT10..  0 (  X  C @     S `@ 0    H  0޽h ? 3380___PPT10..0&0 nf(    S |@ 0   `:communicate (internally & externally) Communicate Culture ;H  0޽h ? 3380___PPT10./j 0 (    S @ 0   Ypeople w/ first hand knowledge of incident & process; interdisc., include leadership resolve contradictory - raises questions, explores "cause" - some prefer term "contributory factor" (complexity/ litigation) Individual vs System Blame Staff "SET-UP" Why = favorite question of 4 yoa. Most freq in kindergarten, least freq in High School ZH  0޽h ? 3380___PPT10./@tj "0 0(  H  0޽h ? 3380___PPT10./j0 '(  X  C @     S ,ص@ 0   too busy going from one incident to another: RCA OPPORTUNITY TO REFLECT must have support of management, view (culture) of CQI, analytic process, not just meeting reg requirement that is not value added not inexpensive (must want to learn about performance) faulty systems rather than intended error - put people in situations, "set-up" healthy org- accepts respons. for actions of staff & residents go beyond incident rates to WHY RISK ASSESMENT ON INDIVIDUAL OR ORG LEVEL (can be used to identify hi risk sit/env WHY IS MOST FREQUENT QUESTION OF 4 YOA (one study shows most frequently asked in kindergarten, less frequently asked in high school)  H  0޽h ? 3380___PPT10./@ 0 H@0(  0X 0 C @   @ 0 S <@ 0   History of org Henry Ford - opportunity for do-over Insanity - Willingness to do RCA communicates culture of willingness to learn Must be prepared: role release, not puntative H 0 0޽h ? 3380___PPT10.4;0 WO4(  4X 4 C @   O 4 S V@ 0   Provide feedback of strengths & weaknesses Was everything done to prevent/< severity Was situation handled appropriately (how fits in w/ other incidents of person, provider Don't rely on compliance to determine quality (necessary, not sufficient). Consider aims of consumers, families, board members,... What are specific issues the affect: staffing (emp rate, union, turnover); media attn; support level HOW DO YOU KNOW YOUR RM SYSTEM IS WORKING H 4 0޽h ? 3380___PPT10.:ѧu=0 wo8(  8X 8 C @   o 8 S ܱ@ 0   Org may be driven by compliance, but compliance necessary but not sufficient for effective organization Compliance requires "protection from harm", but increased health & safety requires going beyond this FLOOR OF EXPECTATIONS H 8 0޽h ? 3380___PPT10.A`E9?0 PI(  P^ P S @    P c $@ 0   ?policies give clear DEFINITION & STRUCTURE to data collection - CONSISTENCY to process (collect, review, interpreat data, outlines oversight represent cyclical approach to R. mgt: (a) proactive (preventative), (b) reactive (managing individual risks), building capacity (based on analysis of both incidents & risk factors) to factor back into prevention Gives guidance to DAY to DAY Shows FORETHOUGHT/preparation of how to respond in advance of an incident (sets QA/investigation, etc in motion Communicates internally & externally  H P 0޽h ? 3380___PPT10.,`feC0 pu(  p^ p S @    p c $ŵ@ 0   kE1.data collection, based on clear definitions from policy; consistend across organization, 2. Reporting EASY INPUT/RETRIEVAL 3. verification: incident review, (by whom, may have levels of review, may vary per type of incident, how are results of review utilized); investigation (internally &/or by outside agencies): should be spelled out in policy & internal (QA) process established to monitor -discuss in more detail on next slide 4. data analysis - ALLOWS FOR MULTI-DIMENSIONAL MITIGATION STRATEGIES (ORG WIDE/STATE WIDE APPLICABILITY discuss in more detail 5. how system alert to under reporting (prior victimizations, previous A/N, unknown injuries, situations existed for long time) COMPILE & ORGANIZE TO - REFLECT AGAINST OBJECTIVE MEASUREMENT - PROVIDE OBJECTIVE/ SYSTEMATIC MONITORING - MEASURES AGAINST BENCHMARKS FH p 0޽h ? 3380___PPT10..ɇr %6 0Zc]I.t%~C'A~6z>g@0@ɉL ݋ӍOQUKYv] MF'<a d`nQTWml@N &0D otOh+'0Q hp  Slide 1 id Textured mariaed70iMicrosoft PowerPointP@9@ر)@fS1pGPg  R('& &&#TNPPw2OMi & TNPP &&TNPP     'A x(xKʦ """)))UUUMMMBBB999|PP3f3333f333ff3fffff3f3f̙f3333f3333333333f3333333f3f33ff3f3f3f3333f3333333f3̙33333f333ff3ffffff3f33f3ff3f3f3ffff3fffffffff3fffffff3f̙ffff3ff333f3ff33fff33f3ff̙3f3f3333f333ff3fffff̙̙3̙f̙̙̙3f̙3f3f3333f333ff3fffff3f3f̙3ffffffffff!___wwweBeBBBB_BeB_BBBBeB?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root EntrydO)PicturesbCurrent UserSummaryInformation(QPowerPoint Document(2DocumentSummaryInformation8