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Navigating Investigations Through Effective Triage Processes
Valerie Smith, MS, RN, FRE Associate Director
Arizona State Board of Nursing
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Road map
u Overview: CORE Discipline Subcommittee u Review “investigative wisdom” u Pinpoint 3 primary stages of complaint investigation
process u Discuss effective complaint receipt & triage practices
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Commitment to Ongoing Regulatory Excellence (CORE)
u Validate promising practices: Discipline
u Several focus groups: identified need for investigation & discipline resources
u Subcommittee selected 10 states identified as high performing in area of discipline
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Discipline subcommittee
Mary Blubaugh (KS)
Barbara Damchik-Dykes (MN)
Tony Diggs (TX)
Lisa Ferguson-Ramos (OH)
Lisa Griffitts (OK)
*Lindsey Erickson (NCSBN)
Eric Holsapple (IA)
Chris Sansom (NV)
Lori Scheidt (MO)
Valerie Smith (AZ)
Mary Trentham (AR)
*Joey Ridenour (AZ) CORE
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Discipline subcommittee charge
Create an adoption plan for effective practices in the area of discipline member boards can utilize to improve performance in overall discipline practices.
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Why is this work important?
u Public protection is served by conducting complaint investigations in a systematic, timely & unbiased manner.
u Investigative evidence obtained guides decision-making & appropriate case resolutions.
u Resources are limited - essential to use efficiently & effectively.
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True or false?
Investigations & discipline is the largest expenditure for most if not all boards?
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True!!
Twenty states provided discipline budget information in 2013 NCSBN Member Profiles totaling:
$57,503,222
Average spent on investigations per board:
$2,875,161
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Collective wisdom investigative experts
u Examine new regulatory evidence & explore new practices while remaining focused on public protection
u Guidelines & thresholds for opening cases enables focus on high risk/harm cases
u Timely complaint resolution & right outcomes enhances public protection
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Collective wisdom: Investigator competence
u Discipline work is complex, not easily learned
u Often takes newly hired investigative staff 12 -18 months to learn essential competencies
u Right investigative outcomes depend upon investigator being able to: u Identify & collect information/evidence
u Effectively communicate: verbal & written
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Collective wisdom investigative experts
u Individuals involved in complaint process not always truthful. Information must be collaborated (evidence)
u Complaint outcomes should focus on identifying deficits/causation & tools to remediate
u Individuals who demonstrate insight & accountability more likely to benefit from remediation
u Types of complaints & complexity has increased
u Multifaceted complaints take longer & require competent investigators & decision-makers
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Three major stages in discipline process
1. Triage/Case Assignment
2. Investigation
3. Resolution
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Complaint triage & case assignment effective practices
u Create thresholds for opening/assigning complaint investigation u Focus upon complaints representing potential higher risk
to public safety
u Generate clear guidelines & policies outlining the complaint intake decision-making process
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Complaint triage & case assignment effective practices
u Standardize online complaint form & instructions u Respondent identification & contact information u Respondent employment information/status u Guided narrative (who, what, when, where, why,
how) u Patient identifying information u Witness(s) identification/contact information u Complainant contact information
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Benefits of standardized complaint intake process & form
u Informs the complainant of information needed u Promotes consistent reporting of vital
information u Facilitates ability to timely assess risk/harm &
assign priority status u Simplifies ability to assign complaint to
investigator with expertise
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Complaint triage & case assignment effective practices
u Designate primary person accountable for receipt, review & assignment u First –ascertain jurisdiction u Second – does case meet criteria/threshold for opening/
assigning?
u Assign case priority/risk level u Based upon the received initial information u Risk may change as new information received u Delegate authority to investigator to modify as new
information is understood
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Priority I examples: High risk & high harm
u Substantial & significant emotional, physical, financial abuse
u Sexual misconduct involving patient(s) u Active & severe impairment u Death or patient harm r/t reckless care or lack of
care u Deliberate harm to patient(s) u Criminal conduct: rape, murder, child molestation
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Priority II examples: Serious violation(s)
u Recent or active SUD u Drug diversion, RX fraud u Mistakes indicative of lack knowledge, skill or ability u Failure to assess & intervene u Theft from patient, family, employer u Action in other jurisdiction limiting or removing
ability to practice & licensed in your state
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Priority III examples: Low risk/low harm
u Inconsequential practice errors; isolated medication error
u Documentation mistakes u Exceeding SOP without harm or pattern u Breech of confidentiality u Positive UDT without evidence of impairment or
inability to safely practice u Driving under the influence without other indicators
of SUD
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Priority IV examples: Minor violations
u CEUs not completed
u Minor isolated mistake not indicative of lack of knowledge, skill or ability
u Action in other jurisdiction for minor violation in that jurisdiction (Censure, Civil Penalty) or actions that do not violate state NPA
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Intake/triage responsibilities
u Assign investigator based upon expertise & capacity
u Coordinate notification to complainant & respondent
u Prepare initial subpoenas & requests for information
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Triage: Additional effective practices
u Assign multiple complaints involving same licensee to same investigator
u Assign complaints involving multiple licensees for same incident(s) to one investigator
u Resourceful as one person receives, reviews records, interviews witnesses, gathers evidence
u Promotes continuity and appropriate resolutions
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Effective triage practices continued
u Standardized form to document complaint & triage activities u Communicates triage activities to investigator &
others
u Improves ability to track information requested & received
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Additional effective complaint processing practices
u Track all complaints: u receipt in agency to resolution
u by licensee/individual, not license number
u investigative cycle timelines: case specific & overall averages; case type; priority/risk; assigned investigator; assigned legal counsel
u simplifies future analysis of various measures to improve processes based on evidence
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Summary of complaint triage & assignment
Significant first stage in the discipline process impacting:
u Investigation
u Case resolution
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Questions?
Thank you!