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  1. 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

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

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

  4. 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. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  5. 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

  6. 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

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

  8. (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 Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  9. (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

  10. (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

  11. 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

  12. 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

  13. 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

  14. 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

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

  16. 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

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

  18. 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

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

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

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

  27. Investigator Qualifications • Other background: • 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

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

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

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

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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

  41. 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

  42. 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

  43. 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/ Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

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

  45. 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

  46. 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

  47. 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

  48. 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

  49. 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

  50. 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