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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