comprehensive & integrated incident management dbhdd hospital system february 2012
DESCRIPTION
Incident Management Policy IncidentsReportsI Level ReviewII Level ReviewIII Level Review Physician ReviewActions RPT/IDT Investigation IRC QMTRANSCRIPT
Comprehensive & Integrated Comprehensive & Integrated Incident ManagementIncident Management
DBHDD Hospital SystemDBHDD Hospital System
February 2012February 2012
Incident Management Policy Incident Management Policy (Policy #: 03-515)(Policy #: 03-515)
• Reporting Incidents• Three-level Reviews• Investigations• Incident Review Committee• Performance Improvement
Incident Management PolicyIncident Management Policy
Incidents Reports I Level Review II Level Review III Level Review
Physician Review Actions
RPT/IDT
Investigation
IRC
QM
1 2 3 4
5
6
7
8
9
Risk Management Policy Risk Management Policy (Policy #: 03-601)(Policy #: 03-601)
• Risk Assessment (Attachment B)• Reporting Triggers & Thresholds
(Attachment A)• Multi-level Reviews (Attachments C, D,
and E)• Performance Improvement
Risk Management PolicyRisk Management Policy
Triggers RPT/IDT
Database
DataAnalysis
Review
Intervention
HRC
Chart
IRP
Implement
review
Recommend
Monitor
QC
Review
CAP
Oversight
1
2 3
4
5
6
7
8
9
10
11
12
HRC Minutes QC Minutes
HighRiskList
Quality Management ManualQuality Management Manual
• Data Collection & Analysis• Quality Management Review• Corrective Action Plan
Incidents Reports I Level Review II Level Review III Level Review
Process Integration Process Integration
Triggers RPT/IDT PRC QC
RPT/IDT QM
Decision Making Process & ResponsibilitiesDecision Making Process & Responsibilities
• Reporting Incidents• Incident Notification• Protecting Consumers• Reassignment of Employees Involved in
Incidents• Investigation• Quality Management Review
Monitoring and AccountabilityMonitoring and Accountability
• Reporting Incidents• Three-level Reviews• IRC Minutes• Investigations• Reporting of Triggers & Thresholds• Risk Assessment• Triggers & Thresholds Review• Corrective Action Plan
Documentation & Record KeepingDocumentation & Record Keeping
• Medical Record/Chart• Three-level Review• HRC Minutes• IRC Minutes• QC Minutes• CAP• PI Plans• Audit Reports
Incident ExampleIncident Example(For Training Only)(For Training Only)
An AMH consumer was agitated and pacing on the unit all morning. Around noon time, he went into his bedroom and picked up a light-weight plastic chair. He came out and threw the chair at a HST. The HST tried to run away from the consumer, but was tripped and fell to the floor. The chair hit the HST. Two other HSTs in the day room saw the situation. They jumped on the consumer and knocked him to the floor. All three HSTs started hitting and kicking the consumer. There were two more HSTs in the area. The incident was not reported until the consumer told a nurse a day later that he was beaten by staff.
The consumer was admitted about a week ago prior to this incident. He had had three incidents involving aggression towards staff. Two of the three HSTs involved in the incident were attacked by the consumer before this incident. They were also accused of abusing consumers in the past. But the investigations didn’t substantiate any allegation.
How should this incident be managed?