Transcript Document

Expect the Unexpected: Are We Clearly Prepared?
“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
Council on Licensure, Enforcement and Regulation
2006 Annual Conference
Alexandria, Virginia
Facing the Frontline
Karen McGovern
Manager, Investigations
College of Nurses of Ontario
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Outline
1. Background
2. Executive Director Actions
3. ART: Risk Assessment Tool
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 15002000 complaints, reports and
inquiries each year.
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
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
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
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
(a) Bank
•
•
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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
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
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
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.
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
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
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?
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
[email protected]
www.cno.org
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
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Investigations - Overview
• Investigative Processes
• Investigator Qualifications
• Case Streaming
• Benchmarks, Reports & Audits
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
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Investigative Processes
• Consider different
– statutory requirements
– fairness requirements
– priorities
= case management implications
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Investigator Qualifications
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Generalist vs. specialist
Education vs. experience
Other background
Interview and testing
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
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
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
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
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
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
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Investigator Qualifications
• Other background:
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–
–
–
Mediation, conflict resolution skills
Analytical skills
Language skills
Time management/office/
administrative skills
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Investigator Qualifications
• Interview and testing
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–
–
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Situational questions
Maturity
Analytical skills
Detail orientation
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Case Streaming
– Prioritizing investigations
– Generalist vs. specialist
– Investigation vs. resolution
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Case Streaming
• Prioritizing investigations:
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“Triage”
“Critical” vs. “High Profile” vs. “Regular”
Resource implications
Timeline implications
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
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
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
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
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
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
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
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)
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
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
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
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.
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
[email protected]
http://www.cpso.on.ca/
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Busting Discipline Backlogs
Claudia Skolnik
Manager, Investigations & Resolutions
Ontario College of Pharmacists
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
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
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
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
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
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
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
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
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
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)
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
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
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
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
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
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Speaker Contact Information
Speaker Name Claudia Skolnik
Organization Ontario College of Pharmacists
Address
483 Huron Street,
Toronto, Ontario, Canada M5R 2R4
Phone, Fax
E-mail
Website
416 847 8238
[email protected]
www.ocpinfo.com
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia