risk management (rm) program reporting and revised forms · 1 last revision 12/20/17 nlf risk...

1

Last Revision 12/20/17 nlf

Risk Management (RM) Program Reporting and Revised Forms

In order for KDHE- Health Facilities Program to better assist facilities with their Risk Management

Programs, Health Facilities Risk Management Reporting is converting to an electronic system/E-files. RM forms

and the RM reporting processes have been revised to maintain a consistent and user-friendly system of E-files and

RM reporting for all.

A major feature working toward consistency is our new centralized Risk Management email mailbox. You may

submit all of your Individual Incident Reports (IIR), Quarterly Reports (QR), RM Plans and any RM inquiries

electronically to [email protected].

[email protected]

Use the KDHE RM mailbox (listed above) for all of your RM submissions.

Private

Secure

Encrypted

Dedicated

Shared by RM Team at KDHE

*Just remember your Who/ What/ When in the Subject Line!

**And your CCN/ State ID # in the document.

mailto:[email protected]


2


Naming Convention Requirements for All Risk Management Communications:

When utilizing communication activities to include the new centralized RM mailbox-- you must complete the

Subject Line with the following 4 Naming Conventions:

Who: Name of Institution

What is the action: Individual Incident Report (IIR); Quarterly Report (QR); Inquiry; RM Plan

Date: Date incident occurred or Date RM Plan submitted to KDHE

In addition- the CNN # or State ID#: (If your facility is not Certified, Include your State ID#) is required

to be on every document when submitted. This includes the IIR, QR, RM Plan, and/or Inquiry.

Note- Clarification regarding the various reporting dates:

Date of the Incident is the Static Date. (This is different than the date sent to KDHE)

Always use this date as your reference date, especially when referring to IIR’s. An example is

(Horton_IIR 4-2-17) (Who/ What/ When)

And then include in document your CCN/ State ID#

Example: Risk Management Mailbox: [email protected].

Naming Convention: Subject line: ABC Company Inc._RM QR1,_3-24-17.

ABC Company Inc._IIR Q3, 4-12-17.

ABC Company Inc._2018 RM Plan 1-15-18

ABC Company Inc. _Inquiry 5-5-17

All facilities should begin using the new system and forms from this point forward.

Note- All reports submitted on or after January 1, 2018 that are not completed on the new forms and are not

following the “Subject Line” protocol of Who, What and When and/or CCN/ State ID#-------------------will be

returned as unprocessable.

The revised forms along with training tools, samples and examples are to assist your facility in building a strong

and successful Risk Management Program can be found on the KDHE website at

http://www.kdheks.gov/bhfr/state_ach_licensure_forms.html.

Scroll down under “Risk Management” to locate various revised forms and sample tools.


http://www.kdheks.gov/bhfr/state_ach_licensure_forms.html

3


Health Facilities would like to thank you for participating every year in the “Survey Monkey”.

Your response provides us with valuable information towards building strong Risk Management Programs.

You can look forward to future Survey Monkeys and training coming your way.

LaDonna Lee

Sr. Administrative Assistant/RM Coordinator

KDHE/BCHS/Health Facilities Program

1000 SW Jackson St., Suite 330

Topeka, KS. 66612-1365

785-296-1249

Fax: (785) 785-559-4250

Nelleda L. Faria, RN, BSN, MBA, PMP, CPHRM

Health Facility Surveyor- Risk Manager/ OASIS Education Coordinator



Topeka, KS. 66612-1365

Ph: 785-296-4714

Fax: 785-559-4250

[email protected]

4


PAGE LEFT INTENTIONALLY BLANK

5


TABLE OF CONTENTS

Topic Page #

Introduction to Risk Management Program

Page 1

Individual Incident Reporting (IIR) Instructions

Page 6

Individual Incident Reporting (IIR) Cover Page

Page 9

Individual Incident Reporting (IIR) Form

Page 10

Quarterly Reporting (QR) Instructions

Page 12

Quarterly Reporting (QR) Cover Page

Page 14

Quarterly Reporting (QR) Form

Page 15

6


Instructions on How to Complete the

Individual Incident Report (IIR)

**Cover Page Must Be Completed and Returned With the Report**

Every finalized SOC III and/or IV incident that occurs within the medical care facility must be reported to KDHE

on the IIR form upon determination of the final SOC. KDHE is the licensing body or agency over your facility or

institution.

Please note that any IIR a Risk Manager (RM) deems necessary can be submitted to KDHE.

All IIRs should be sent to KDHE upon determination of the SOC(s).

Please mark any applicable referral that you make to an individual’s licensing board or agency, if applicable with

the incident.

Cover Page

Please complete the name and address listed on the facility license. Do not use initials.

Be sure to enter the CNN#. This is the # assigned by CMS when your facility became certified. It always starts with 17_ _

_ _

Note: *CCN is CMS Certification Number: If your facility is not CMS Certified, please list State ID#

Type of facility: If you are a general hospital with a psychiatric unit, check “Hospital.” only.

Facility Address Information

Risk Manager Name and Title with contact information.

Risk Manager Attestation Signature and Date

Regarding patients: Always remember to redact patient name(s), dates of birth, social security numbers, and other

individually identifiable information from the report submitted to KDHE.

Regarding staff: Always remember to redact staff names(s), dates of birth, licensure numbers and other individually

identifiable information from the report submitted to KDHE.

7


Instructions on How to Complete the

Individual Incident Report (IIR)

IIR Report Form

1. Facts of the Incident section is where the detailed description of what happened is put. This section answers the

Who, What, When, Where, Why and How (5W1H).

2. Standard of Care (SOC) Determination and Assignment- Please list the various owners and the associated SOC

assigned for each.

3. Describe the corrective actions taken to remediate the incident or prevent occurrence/ re-occurrence:

4. Select the corrective action category taken to remediate the incident or prevent occurrence/ re-occurrence:

5. Complete findings from Root Cause Analysis (RCA) for failure/ Specify recommendations for Minimizing Future Occurrences from the system failure or identified cause.

6. Indicate the category type of incident/occurrence

7. Mark on the IIR form which licensing agency(ies) the referral was sent to.

8. Submit your IIR to the E-file address listed below.

9. Please remember to submit any Risk Management correspondence using the revised Naming Convention

Policy of otherwise your documentation will be returned.

Who

What

When (use the Date of the Incident as your date)

CCN#

Example: ABC Inc. QR2 7-25-16

Kansas Department of Health and Environment

Bureau of Community Health Systems

Risk Management Program

1000 SW Jackson Street, Suite 330

Topeka, Kansas 66612-1368

8


Email to [email protected]

Or Fax to (785) 559-4250

Retain the original of the IRR forms and attach it with the Quarterly Report (QR) summary for each

applicable reporting quarter.

All SOC III and IV IIR reports are submitted as soon as the final SOC determinations are made.

If there is a concern regarding an Incident that is egregious, potential for headlines, or other high profile

or unique situation that may need discussion or recommendations--- please call the KDHE Risk Manager.


9


Confidential Cover Page

RISK MANAGEMENT INDIVIDUAL INCIDENT REPORT (IIR) FORM

Risk Management SOC 3 AND 4

28-52-2. Incident reporting. (a) Each medical care facility shall identify a written form on which employees and

health care providers shall report clinical care concerns to the risk manager, chief of staff, or administrator. The

original or complete copy of the incident report shall be sent directly to the risk manager, chief of staff, or

administrator, as authorized in the facility's risk management plan. (b) The risk manager, chief of staff, or

administrator shall acknowledge the receipt of each incident report in writing. This acknowledgment may be made

in the following manner: (1) file stamping each report; (2) maintaining a chronological risk management reporting

log; (3) signing or initialing each report in a consistent fashion; Or (4) entering pertinent information into a

computer database. (c) Incident reports, investigational tools, minutes of risk management committees, and other

documentation of clinical analysis for each reported incident shall be maintained by the facility for not less than

one year following completion of the investigation. (Authorized by and implementing K.S.A. 65-4922; effective

Feb. 27, 1998.)

Name of Facility *CCN# 17-_________

Facility Type: Hospital [ ] Psychiatric Hospital [ ] Ambulatory Surgical Center [ ] Other [ ]____________

Address City ___________________________

Name and Title of Risk Manager_________________________________________________________

Email address ________________________________________________________________________

Phone Number Date: _____________________________ *CCN is CMS Certification Number: If your facility is not CMS Certified, please list State ID#

With this submission, as the above listed Risk Manager I hereby attest that the report submitted to Kansas Department of Health and Environment is true, complete and accurate to the best of my knowledge without known errors or omissions.

Signature ___________________________Date___________________

10


INDIVIDUAL REPORTABLE INCIDENT REPORT FORM

SOC 3 / 4 RISK MANAGEMENT

Date of the Incident:_______________ Date Incident Reported to RM:__________________

1. Facts of the Incident (Detailed description to include who, what, where, when, why, and how ): (Please attach

additional sheets as needed)

2. Standard of Care (SOC) Determination and Assignment:

3. Specify corrective actions taken to remediate the incident or prevent occurrence/ re-occurrence:

11

PRIVACY & CONFIDENTIALITY NOTICE: This communication as part of Risk Management is protected information and non-discloseable

or discoverable. This is including any attachments, may contain confidential information and is intended only for the individual or entity to which

it is addressed as part of the Risk Management Program. Any review, dissemination, or copying of this communication by anyone other than the

intended recipient is strictly prohibited.

INDIVIDUAL REPORTABLE INCIDENT REPORT FORM

SOC 3 / 4 RISK MANAGEMENT

4. Indicate the corrective action taken such as □ Policy / Procedure Change □ Suspension of Privileges

□Termination □ Counseling / Education □ Restriction of Privileges □ Revocation of Privileges □ Pending

□ Other: __________________________________

5. Root Cause Analysis (RCA) for failure/ Specify recommendations for Minimizing Future Occurrences:

6. Indicate the category type of incident/occurrence such as:

□ Fall □ Abuse, Neglect or Exploitation □ Assessment/treatment □ Professional licensure event □

Delay □ Facility process or system-related □ Scope of Practice □ Impairment due to drug, alcohol or

cognition □ Falsification □ Documentation of Narcotics □ Medication Error □ Improper Procedure □

EMTALA-Related □ IV line mix-up □ Drug Diversion □ Unprofessional conduct □ IV infiltration

□ Other: __________________________________

7. All reports are submitted to KDHE as the licensing agency. In addition, please indicate any referral

reports sent to following additional licensing agencies. There is no need to attach evidence of referral.

Board of Healing Arts Board of Nursing Board of

Pharmacy Other

12





Instructions on How to Complete the Risk Management Quarterly Report

(QR)

**Cover Page Must Be Completed and Returned With the Report**

Please complete the name and address listed on the facility license. Do not use initials.

Be sure to enter the CNN#. This is the # assigned by CMS when your facility became certified. It always starts with

17_ _ _ _ If your facility is not CMS Certified, please list the Facility State ID#__________.

All reportable incidents must be reported to KDHE on the IIR form upon determination of the final numbers.

All quarterly reports should be sent to KDHE within 30 days of the end of the report quarter.

The due dates are April 30th

, July 31st

, October 31st

and January 31st

10. Type of facility: If you are a general hospital with a psychiatric unit, check “Hospital.” only.

Year: Make sure you document the year and the quarter that is listed.

First quarter = January, February and March

Second quarter = April, May and June

Third quarter = July, August and September

Fourth quarter = October, November and December

11. If you have an IIR that has occurred during your current Quarterly Reporting quarter but you are waiting

on a determination from your facility Advisory Board---

a. Check the box indicating this on the QR form and submit another REVISED QR for said quarter

when you receive the determination.

b. When submitting the REVISED QR to KDHE be sure and check the appropriate box. Also include

any IIR and referral hashes, when appropriate.

12. Total number of final SOC determinations by the facility’s risk management program this quarter:

Reporting of SOC III and IV determinations are mandated but you may report anything at any time.

13. Specify the individual number of referrals sent to each of the individual licensing agencies. If you select

“Other” please provide explanation.

14. Identify the appropriate category type of each individual incident (IIR). If you select “Other” please

explain.

15. Submit your QR to the E-file address listed below. Please remember to submit any Risk Management

correspondence using the revised Naming Convention Policy of otherwise your documentation will be

13





returned.

Who

CCN#

What

Date submitted to KDHE

Example: ABC Inc. QR2 7-25-16

Kansas Department of Health and Environment

Bureau of Community Health Systems


1000 SW Jackson Street, Suite 330

Topeka, Kansas 66612-1368

Email to [email protected]

Or Fax to (785) 559-4250


14





Confidential Cover Page

Quarterly Report (QR) Pursuant to KSA 65-4923(d)

(d) Each review and executive committee referred to in subsection (a) shall submit to the secretary of health and environment, on a

form promulgated by such agency, at least once every three months, a report summarizing the reports received pursuant to

subsections (a)(2) and (a)(3) of this section. The report shall include the number of reportable incidents reported, whether an

investigation was conducted and any action taken.

Reporting Year ___________ Reporting Quarter ____________

Check this box if this is an amendment to a previous QR report submitted. What Quarter? _____

Check this box if you have an IIR occurred but not reported this QR because waiting on decision from Advisory

Board as to the determination and you will be submitting KDHE and amended QR after determination.

Name of Facility *CCN# 17-_________

Address City ________________

Name and Title of Risk Manager

Email address ________________________________________________________________________

Phone Number Date Sent to KDHE: ____________

*CCN is CMS Certification Number: If your facility is not CMS Certified, please list State ID#

With this submission, as the above listed Risk Manager I hereby attest that the report submitted to Kansas Department of Health and Environment is true, complete and accurate to the best of my knowledge without known errors or omissions.

Signature Date______________________

15





KANSAS DEPARTMENT OF HEALTH & ENVIRONMENT


Confidential Quarterly Report Pursuant to KSA 65-4923(d)

Please type or use a black pen when completing this form.

Reports are due within 30 days of each completed quarter.

Facility Name: _________________________ City: ______________

*CCN# 17-______________ CCN is CMS Certification Number: If your facility is not CMS Certified, please list State ID#

1. Facility Type: Hospital [ ] Psychiatric Hospital [ ] Ambulatory Surgical Center [ ] Other [ ]

2. Year: __ Reporting Quarter: Jan.-March [ ] April-June [ ] July-Sept. [ ] Oct.-Dec. [ ]

3. Total number of final SOC determinations by the facility’s risk management program this quarter:

(All individual incident reports are reported to KDHE upon final determination with the details.)

a.

Total number of final SOC III (standard of care not met with injury occurring

or reasonably probable) determinations.

b.

Total number of final SOC IV (possible grounds for disciplinary action by the

appropriate licensing agency) determinations.

4. Specify the individual number of referrals submitted to each of the following additional licensing agencies:

# Board of Healing Arts # Board of Nursing # Board of Pharmacy

# Other: _________________________________________ (List total names as applicable)

5. Indicate the category type of each individual incident/occurrence such as:

___ Fall

___ Abuse, Neglect or Exploitation

___ Assessment/treatment

___ Professional licensure event

___ Delay

___ Facility process or system-related

___ Scope of Practice

___Impairment due to drug

___ Alcohol or cognition

___ Falsification

____ Documentation of Narcotics

____ Medication Error

____ Improper Procedure

____ EMTALA-Related

____ IV line mix-up

____ Drug Diversion

____ Unprofessional conduct

____ IV infiltration;

____ Other:______________________________

PRIVACY & CONFIDENTIALITY NOTICE: This communication as part of Risk Management is protected information and

non-discloseable or discoverable. This is including any attachments, may contain confidential information and is intended only

for the individual or entity to which it is addressed as part of the Risk Management Program. Any review, dissemination, or

copying of this communication by anyone other than the intended recipient is strictly prohibited.

Nelleda L. Faria, RN, BSN, MBA, PMP, CPHRM

Health Facility Surveyor- Risk Manager/ OASIS Education Coordinator



Topeka, KS. 66612-1365

Ph: 785-296-4714

Fax: 785-559-4250

[email protected]

Return this report to:

LaDonna Lee

Sr. Administrative Assistant/RM Coordinator



Topeka, KS. 66612-1365

785-296-1249

E-mail report to [email protected]

Fax: (785) 785-559-4250

Data Collection Purpose: The purpose of the data collection activity is solely for usage as business analytics for the KDHE Risk

Management Program. This includes but is not limited to overall Risk Management Program business intelligence, enterprise

information management, enterprise performance management, analytic applications, and governance, risk, and compliance.



risk management (rm) program reporting and revised forms · 1 last revision 12/20/17 nlf risk...

Documents