Breaking the Bottleneck Case Management: Unplugged

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Breaking the Bottleneck- Case Management
Unplugged
Expect the Unexpected Are We Clearly Prepared?

• 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
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Facing the Frontline

• Karen McGovern
• Manager, Investigations
• College of Nurses of Ontario

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Outline

• Background
• Executive Director Actions
• ART Risk Assessment Tool

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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.

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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

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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

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Executive Director Actions

• Three levels of Executive
• Director Action
• Bank
• Investigate
• Invitation to Provide Assurances

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(a) Bank

• The matter is not inherently serious and does not
  require a full investigation
• Notify nurse of report received and outline
  regulators expectations for practice in future
• Report retained on file matter is not closed.
  Can be investigated if further matters are
  reported in the future

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(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

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(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

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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.

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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

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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

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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?

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Speaker Contact Information

• Karen McGovern, RN LLB
• College of Nurses of Ontario
• Toronto, Ontario, Canada
• [phone]
• kmcgovern_at_cnomail.org
• www.cno.org

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Cracking Cases

• Angela Bates
• Manager, Committee Support
• and Compliance Monitoring
• College of Physicians Surgeons of Ontario

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Investigations - Overview

• Investigative Processes
• Investigator Qualifications
• Case Streaming
• Benchmarks, Reports Audits

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Challenges and Strategies

• Protocol for identifying categories
• Investigative Processes
• Clinical care vs. incompetence vs. professional
  misconduct vs. member incapacity case management
  implications

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Investigative Processes

• Consider different
• statutory requirements
• fairness requirements
• priorities
• case management implications

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Investigator Qualifications

• Generalist vs. specialist
• Education vs. experience
• Other background
• Interview and testing

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Investigator Qualifications

• Generalist vs. specialist
• E.g., individual with education/ experience over
  broad areas vs. individual with specific, deep
  knowledge in one area

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Investigator Qualifications

• Generalist
• Pros
• Can manage multiple types of investigative
  processes case management implications
• Versatility budget implications

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Investigator Qualifications

• Generalist
• Cons
• Quality of investigative work in specialized
  matters
• Depth of knowledge e.g., misconduct and
  incapacity investigations very different

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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

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Investigator Qualifications

• Specialist
• Cons
• Less cross-training budget and case management
  implications
• Unable to see forest for trees missing important
  indicators, too focused

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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

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Investigator Qualifications

• Other background
• Mediation, conflict resolution skills
• Analytical skills
• Language skills
• Time management/office/ administrative skills

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Investigator Qualifications

• Interview and testing
• Situational questions
• Maturity
• Analytical skills
• Detail orientation

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Case Streaming

• Prioritizing investigations
• Generalist vs. specialist
• Investigation vs. resolution

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Case Streaming

• Prioritizing investigations
• Triage
• Critical vs. High Profile vs. Regular
• Resource implications
• Timeline implications

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Case Streaming

• Prioritizing investigations
• Pros
• Important matters have more attention and
  resources focused on them move more quickly
  public interest protected

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Team Structure (CPSO)

• Generalist vs Specialist
• Shared investigations
• Delegation of investigation steps
• Communication consistency
• Template correspondence and filing

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Case Streaming

• Prioritizing investigations
• Cons
• Tendency to back-burner less urgent matters
• Need to balance less critical and more critical
  efficiency and thoroughness

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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

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Case Streaming

• Timeline implications
• Different benchmarks for prioritized matters?
• Challenge meet benchmarks on all types of matters

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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

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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

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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)

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Benchmarks, Reports Audits

• Reports
• Online administrative tracking systems capacity
  to produce regular reports, batch requests and
  responses to individual queries

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Benchmarks, Reports Audits

• Reports
• Need for regular production of reports
• Benchmarks, high profile cases individual
  investigator, team workloads, timelines
• Need for regular review

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Benchmarks, Reports Audits

• Audits
• Quality assurance mechanism
• Purpose Educational process reform should not
  target performance management

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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.

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Speaker Contact Information

• Angela Bates
• College of Physicians and Surgeons of Ontario
• 80 College Street
• Toronto, Ontario, Canada M5G 2E2
• Tel. [phone]/Fax [phone]
• abates_at_cpso.on.ca
• http//www.cpso.on.ca/

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Busting Discipline Backlogs

• Claudia Skolnik
• Manager, Investigations Resolutions
• Ontario College of Pharmacists

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Overview

• What is a backlog?
• Understanding how it occurred?
• Problem analysis where is the problem?
• What are the issues?
• Opportunities for process improvement

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Fundamental Considerations

• Public Safety
• Public Accountability
• Membership Accountability
• Strategic Direction
• Interim Shift in Prosecutorial Philosophy
• Openness

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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

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Assess Post Referral Information

• Consider interim shift in prosecutorial
  philosophy
• Update post referral information about the member
• Compliance
• Death
• Resignation

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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

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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

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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

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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

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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

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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)

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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

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Legal Considerations

• Delay and Prejudice
• Limitation of Prosecutorial Discretion
• Executive Committee Referrals
• Complaints Committee Referrals
• Conflicts of Discipline Committee members

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Challenges

• Prosecution based on antiquated philosophies
  backlash
• Glut of cases misplaced impression of zealous
  punitive approach

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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

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Key Components for Success

• Clear strategic priority
• Authority and flexibility to recruit team
• Securing financial resources
• Accountable communication strategy

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Speaker Contact Information

• Speaker Name Claudia Skolnik
• Organization Ontario College of Pharmacists
• Address 483 Huron Street,
• Toronto, Ontario, Canada M5R 2R4
• Phone, Fax [phone]
• E-mail cskolnik_at_ocpinfo.com
• Website www.ocpinfo.com