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Involving Stakeholders in TERCAP Implementation

2008 TERCAP FORUMApril 7, 2008

Charlotte F. Beason, Ed.D., RN Executive Director, Kentucky Board of NursingJan Ridder, MA, RN CHE Past Member, Kentucky Board of Nursing

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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

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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

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Involving Stakeholders in TERCAP Implementation

Kentucky Implementation Process

1. 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

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Involving Stakeholders in TERCAP Implementation

Implementation Process continued

2. 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.”

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Involving Stakeholders in TERCAP Implementation

Implementation Process continued

3. Introduce TERCAP instrument

4. Present case studies and discuss issues

5. Formulate Recommendations and forward

to Board

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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

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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.

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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.

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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

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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

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It Takes a VillageKathy Scott

Joey Ridenour

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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

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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.

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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”?

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Discipline System Theory

Human Error Negligent Conduct Reckless Conduct Knowing Violations

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Disciplinary Decision Making

Outcome-Based Rule Based Risk Based

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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

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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

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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

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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

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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

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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

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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.

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Before & After TERCAP

Investigative Case analysis using TERCAP

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Summary & Next Steps

Kathy Scott Joey Ridenour

It Take A Village