module 5: obligation to report - martinhealth.org · subtopic 5.4.2.1: adverse incident subtopic...

Obligation to Report

Module 5

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Directions Reference Material Learning Goals

Go through each slide and read/listen to the information (this module will be marked as ‘Completed Unsuccessfully’ until you have viewed all of the slides) Access and review documents as indicated by searching online or using the links provided in the ‘2017 AME Guide’

Learning Goals are outlined so you are able to identify what is expected of you upon completion of the training.

Learning Guide

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Throughout the Module there will be notes like this

that will list additional materials to access. Refer to

your ‘2017 AME Guide’

(provided at the beginning of this training and as a

downloadable attachment)

Module 5: Obligation to Report

Lesson 5.1: Introduction to Reporting

Lesson 5.2: Reporting Misconduct

Lesson 5.3: Reporting Compliance Concerns

• Topic 5.3.1: How to Report Compliance Concerns

• Topic 5.3.2: Compliance Items to Report Subtopic 5.3.2.1: HIPAA Violations

Subtopic 5.3.2.2: Fraud

Lesson 5.4: Occurrence Reporting • Topic 5.4.1: How to Report Occurrences

• Topic 5.4.2: Occurrence Items to Report Subtopic 5.4.2.1: Adverse Incident

Subtopic 5.4.2.2: Sentinel Events

Subtopic 5.4.2.3: Patient’s Rights

Subtopic 5.4.2.4: Error or Unexpected Event

Subtopic 5.4.2.5: Grievances

• Topic 5.4.3: What MHS does if an occurrence event occurs

Module Outline

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• Name your obligations to report and what you should report

• Identify the document where you find these obligations and where it is located

• Repeat the Reporting telephone numbers

• List the steps to file an occurrence report

• Label the processes used to investigate a sentinel event and to reduce risk

• List a Patient’s rights

Learning Goals

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Introduction to Reporting


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Lesson 5.1

Recall that our Vision is “to be an innovative healthcare system nationally recognized for clinical excellence and improving the health and well-being of the communities we serve”. There are laws, regulations, and MHS policies around reporting that you must follow for us to: • Reach our vision • Be a safe environment that effectively addresses incidents • Prevent future incidents or occurrences

You are obligated to report • Misconduct: associate misconduct concerns • Compliance Concerns: failure to comply with laws, regulations, and

department policies • Occurrences: risk events and feedback

Introduction

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Reporting Options

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Reporting requirements differ based on the event, concern, urgency, severity, etc. Below are a few notes about reporting.

– In general, it is advised to notify your Leader/Chain of Command for advisement if you are unsure what to do.

– Reporting things in iReport will be directed to the correct department.

Unsure how to report?

– Your Leader should be able to advise

– Risk Management, Corporate Compliance, or Human Resources are also available to provide guidance on reporting

– Learn more on MartinLink

MHS Reporting Options

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Leader

Chain of Command

Risk Management Risk Management Department

ext. 15899

Corporate Compliance Corporate Compliance Department

ext. 11983

Chief Compliance Officer ext. 13957

Human Resources Associate Helpline

ext. 12222

iReport

Compliance Hotline 1-877-785-0002 or

www.mycompliancereport.com code MMH

iReport

http://www.mycompliancereport.com/

Generally, these are the type of reporting topics the following departments handle.

MHS Departments that Handle Reporting

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Risk Management Corporate Compliance Human Resources

For Risk Events • Patient or non-patient safety

events • Patient/visitor

lost/stolen/damaged property • Associate injuries For Feedback • Patient/client complaints • Patient grievances • Compliments • Suggestions

For HIPAA related concerns • any unauthorized access, use or

disclosure of Protected Health Information [PHI])

For concerns related to the Code of Conduct • examples include: Patient Gifts, Conflicts

of Interest, Vendor Relations, Billing and Coding, and False Claims. (see the MHS Code of Conduct for full list of topics).

For any suspected failure to comply with state or federal laws or regulations or MHS policy

For associate conduct concerns

External Reporting Options

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External Reporting Options

The Joint Commission Hopefully this will be your last resort, but if you have a concern that you feel was not adequately addressed, you may file a safety or quality of care concern directly to Joint Commission:

• Print a Quality Incident Report Form from www.jointcommission.org • Email: [email protected] • Fax: (630) 792-5636 • Mail Joint Commission Office of Quality Monitoring, One Renaissance

Blvd., Oakbrook Terrace, IL 60181 • Questions? Call Joint Commission at (800) 994-6610, 8:30 am to 5 pm

central time, weekdays

Agency for Health Care Administration (AHCA)

• Consumer Services Unit PO Box 14000 Tallahassee, FL 33317 • (888) 419-3456 • http://www.ahca.myflorida.com/contact/links.shtml

Associates and patients ALWAYS have the option to report ANY concerns to the following resources. Throughout this module you will be told how to report within MHS, but please remember that these are also options.

http://www.ahca.myflorida.com/contact/links.shtml

In case of an Emergency

If there is an immediate safety or security concern, you should immediately let the relevant people know in-person or via phone… • Your Leader/Chain of Command • Security/Police (Call Command Center at ext. 15741. If offsite, call 911) • Risk Management • Corporate Compliance • Human Resources

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When unsure, question.

When concerned, report.

MHS and the law prohibit retaliation for good-faith reporting.

The Chief Resource Officer will closely examine claims of retaliation to ensure that

legitimate, non-retaliatory reasons motivated any action taken. If retaliation played a influential part in the action taken, then the Chief Executive Officer will take prompt

and appropriate corrective action against the offender.

Non-Retaliation

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Administrative Policy: Non-Retaliation • You cannot be retaliated against for making a good-faith report

of a compliance concern • Any form of retaliation against an associate who identifies a

perceived problem or concern, in good faith, is strictly prohibited

Other references to non-retaliation and reporting in the Associate Handbook • You cannot be retaliated against for

– Voicing a concern regarding legal regulatory issues, policies and procedures, and/or seeks the aid of Human Resources or files a grievance

– Filing a complaint of harassment – Acting in good faith and reporting a real or implied violent behavior – Reporting variances or medical errors

Non-Retaliation

For additional information: On MartinLink → MHS Code of Conduct On Hospital Portal → Administrative Policy:

Non-retaliation

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Reporting Misconduct


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Lesson 5.2

All associates have the responsibility to immediately report misconduct. This includes

– Theft

– Impaired behavior

– Arrests (If you are arrested, you must self-report to MHS within 48 hours of the arrest)

– Sexual harassment

MHS is committed to investigating all reports of misconduct. If you need assistance or have questions, contact the Associate Helpline at ext. 12222.

Misconduct

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Misconduct Reporting

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Reporting Options for Misconduct

Leader

Chain of Command

Human Resources Sibel Miglino (ext. 11269) or Diane Stachurski (ext. 12215)

Corporate Compliance Department ext. 11983


Compliance Hotline 1-877-785-0002 or www.mycompliancereport.com (code: MMH)


Recall from Module 4:

• Immediately report any actual or potential threats to

– Command Center at ext. 15741

– And to your Leader or Human Resources (Associate Helpline ext. 12222)

• File an iReport

Reporting Workplace Violence

Contact information: → Command Center at ext.

15741 → Associate Helpline ext.

12222

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Recall from Module 4: If you suspect impaired behavior… 1. Immediately notify your leader and Human Resources of suspected Associate

impairment

– During business hours: call Sibel Miglino ext. 11269 or Diane Stachurski ext. 12215

– Off shifts: Notify your Leader/Chain of Command and call the Switchboard Operator and ask them to contact Human Resources

2. Do NOT allow the associate with the suspected impaired behavior to – Go home – Have anything to drink – Use the restroom

A determination will be made by Human Resources if an Associate must undergo physical examination/drug and alcohol testing

3. Fill out the Impaired Behavior Review Form

1. Found on the MartinLink Occupational Health site under ‘Occupational Health Forms’

2. Documentation for suspected impairment must be objective. Document what you

“observe” not what you “think” 3. This form and all related documentation is confidential. 4. Following completion, submit to the Human Resources Department.

Reporting Impaired Behavior

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For additional information: On MartinLink → Impaired Behavior

Review Form Contact Information: → Sibel Miglino at ext.

11269 → Diane Stachurski at ext.

12215

Reporting Compliance Concerns


Lesson 5.3

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A Compliance Concern includes:

– HIPAA violations: any unauthorized access, use or disclosure of Protected Health Information (PHI)

– Violations of the MHS Code of Conduct: examples include Patient Gifts, Conflicts of Interest, Vendor Relations, Billing and Coding, and False Claims (see the MHS Code of Conduct for full list of topics)

– Any suspected failure to comply with state or federal laws or regulations or MHS policy

What is a Compliance Concern?

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• Per our Code of Conduct, associates have an obligation to report suspected failure to comply with laws, regulations, and department policies.

• Failure to report compliance violations will result in disciplinary action.

• If something is troubling you, please call—it’s the right thing to do.

Your Obligation to Report

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• All Associates have the responsibility to immediately report any suspected violations of regulations, laws, or MHS policy.

• MHS is committed to investigating all reports of violations.

• If you need assistance or have questions, contact your leader or chain of command. You can also reach out to Corporate Compliance directly who will either answer your questions or direct you to the correct person/department.

Reporting Violations

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Corporate Compliance



• MHS will apply consequences to associates and medical staff for failure to comply with

HIPAA

MHS Privacy and Security Policies

• Failure to comply with HIPAA – Information on Corrective Actions and consequences for

non-compliance can be found in MHS HIPAA Privacy Policy HIPAA Privacy Policy #29: Corrective Actions

– Procedures for applying corrective action

HIPAA Privacy Policy #29.A: Privacy and/or Security Incident Matrix

– Categories of violations, examples of violations, and possible consequences that may result

– These sanctions range from verbal warning to termination depending on the severity of the violation.

– HIPAA violations can have criminal or civil penalties

Consequences for Non-Compliance

For additional information: On Hospital Portal → MHS HIPAA Privacy Policy

#29 and #29.A

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• Other consequences for failure to comply with HIPAA and other laws and regulations can include:

– Criminal and Civil charges

– Notification to licensing boards

MHS may be required to report the incident to the associate’s licensing board for unprofessional conduct.

For example, the Nurse Practitioner Act includes unprofessional conduct as grounds for disciplinary action. Unprofessional Conduct is defined, in part, by Florida Administrative Code – 649B as “Violating the confidentiality of information or knowledge concerning a patient”.

Consequences for Non-Compliance

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How to Report Compliance Concerns

Lesson 5.3 Reporting Compliance Concerns

Topic 5.3.1

How to Report Compliance Concerns

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Reporting Options for Compliance Concerns

Leader

Chain of Command



Compliance Hotline 1-877-785-0002

or www.mycompliancereport.com (code: MMH)

Department of Health and Human Services (HHS) at www.hhs.gov

Office of Inspector General (OIG) at 1-800-HHS-TIPS


• Use the hotline to report compliance issues if you do not feel comfortable, cannot, or do not want to report something up your chain of command.

• The hotline is – Available 24/7 – Anonymous, if you want – For feedback and follow-

up

Using the Compliance Hotline

Compliance Hotline

By phone at: 1-877-785-0002

On the web at:

www.mycompliancereport.com use code: MMH

*You can be anonymous

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Compliance Items to Report


Topic 5.3.2


HIPAA Violations 29

Subtopic 5.3.2.1


Topic 5.3.2 Compliance Items to Report

• Recall Module 3: Information Safety about HIPAA and Protected Health Information policies

• HIPAA violations are handled by Corporate Compliance.

HIPAA Violations

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Violations of a Patients’ HIPAA Rights can be reported like any other compliance concern.

Accidental accesses and information slips happen. Report if you accidentally disclose Protected Health Information (PHI) OR if you receive PHI (ex: via email) that you should not have received.

• You must immediately report – Unauthorized disclosure of PHI (intentional or accidental)

– Any patient complaint regarding the use or disclosure of PHI

• Let Compliance know so they can

– Help manage the situation

– Understand what we find on an audit

Self-Reporting of HIPAA Violations

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Violations of a Patient’s HIPAA Rights can be reported like any other compliance concern.

Patients have the right to: • Ask to see and receive a copy of their health records

• Have corrections added to their health information

• Receive a notice that tells them how their health information may be used and shared

• Decide if they want to give their permission before their health information can be used or shared for certain purposes, such as marketing

• Get a report on when and why their health information was shared for certain purposes

Patients’ HIPAA Rights

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Violations of a Patient’s HIPAA Rights can be reported like any other compliance concern.

If a patient believes their rights are being denied or their health information is not being protected, they can file a complaint with MHS Corporate Compliance Department or the Department of Health and Human Services (HHS) at www.hhs.gov

Patient Reporting

Contact Information: → Corporate Compliance

at ext. 11983

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Fraud 34

Subtopic 5.3.2.2


Topic 5.3.2 Compliance Items to Report

Fraud: wrongful or criminal deception intended to result in financial or personal gain.

• If you knowingly present a false claim to Medicare or other governmental program, then you will be penalized under state and federal false claims acts.

• If you make a good faith report of a violation, then, you have protections under state and federal false claims acts as the individual making the report.

Fraud

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• Florida is known as a hot-bed for fraudulent health care activity.

• Types of fraud can include billing fraud, identity theft, and more.

• Fraud can be reported like any other compliance concern.

Fraud

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.

Occurrence Reporting


Lesson 5.4

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All associates are obligated to report unexpected, unanticipated events that either did result in harm, or have potential to result in harm (near miss) including:

– Adverse Incidents (can include Code 15 incidents)

– Sentinel Events

– Grievances

– Professional Conduct Concerns

– Threats of litigation

– Suspicion of neglect or abuse

– Suspicions of suicide risks

– Patient or visitor falls

– Lost valuables

– Allegations of sexual misconduct

– Medication variances

– Surgical or procedure complications

Your Obligation to Report

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How to Report Occurrences

Lesson 5.4 Occurrence Reporting

Topic 5.4.1

Review the Administrative Policy: ‘Occurrence Reporting’.

Occurrence Reporting Options

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For additional information: On Hospital Portal → Administrative Policy:

Occurrence Reporting Occurrence Reporting Options

Leader

Chain of Command

Risk Management Risk Management Department ext. 15899

iReport

1.Notify your supervisor

2.Access iReport via MartinLink or through EPIC

3.Select the appropriate icon (ex: Associate Injury/Illness, Fall, Professional Conduct, Safety/Security)

4.Fill out the information

Steps to Fill Out an Occurrence Report

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Steps to Fill Out an Occurrence Report via Martinlink

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If you don’t have access to electronic reporting, call Risk Management at ext. 15899

Steps to Fill Out an Occurrence Report via iReport link directly from Epic

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The link will either be found on the Activity Tabs on the left side of the screen as shown below…

By clicking

on the

‘MORE’

button on

the bottom

and then

clicking on

iReport

NEW

iReport Icons

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Occurrence Items to Report


Topic 5.4.2


Adverse Incident 46

Subtopic 5.4.2.1


Topic 5.4.2 Occurrence Items to Report

An Adverse Incident is an event that health care personnel could exercise control AND that is associated in whole or in part with medical intervention Code 15 adverse incidents must be reported to AHCA (Agency for Health Care Administration) within 15 calendar days. File an iReport and notify Risk Management. (15899 or through Operator after hours)

Code 15: Adverse Incidents

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• Reportable Injuries – Death – Brain or spinal damage – Surgical procedure on wrong patient – Wrong surgical procedure – Surgical procedure medically

unnecessary to the patients diagnosis or medical condition

– Surgical repair or damage when the planned procedure does not include this as a risk on the consent

– Procedure to remove unintended remaining foreign objects remaining from a surgical procedure

Code 15: Adverse Incidents

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Adverse Incidents can be reported through the Occurrence Reporting method


Sentinel Events 49

Subtopic 5.4.2.2



• A sentinel event is an unexpected occurrence involving one or more of the following: – Death – Serious physical injury (loss of limb or function) – Serious psychological injury – Or the risk of any of the above

• MHS may report these occurrences to The Joint Commission so it is extremely important that you report Sentinel Events.

• File and iReport and notify Risk Management

(15899 or through Operator after hours)

Sentinel Events


Patient Safety Plan

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Examples of Sentinel Events include: – Suicide

– Unanticipated death of a full-term infant

– Surgery on wrong patient or body part

– Unintended retention of a foreign object after surgery or procedure

– Hemolytic transfusion reactions involving blood group incompatibilities.

– Any elopement that is “unauthorized departure” of a patient from a staffed around the clock care setting including the ED, leading to death , permanent harm or severe temporary harm to the patient

Sentinel Events: Examples

For additional information: On Hospital Portal for more examples: → Administrative Policy:

Sentinel Event or Adverse Event Medical Incident Review Process

Sentinel Events can be reported through the Occurrence Reporting method

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Patient’s Rights 52

Subtopic 5.4.2.3



Patients have the right to:

• Know their diagnosis, treatment plan, alternatives, risks, and prognosis

• Refuse treatment

• Treatment for an emergency medical condition that will deteriorate from failure to provide treatment

• Effective pain management

• A patient has the right to designate and receive visitors of their choosing. Visitors will be allowed equal access regardless of race, color, national origin, religion, sex, gender identity, sexual orientation or disability, subject to hospital visitation policies. (this includes their support person)

• (Refer to Patient’s Bill of Rights and Responsibilities for full list which is located in the patient’s guide and in the ED and admitting lobbies)

Patient Bill of Rights and Responsibilities

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Violations of a Patient’s Bill of Rights and Responsibilities can be reported through the Occurrence Reporting method

For additional information: On MartinLink → Patient’s Bill of Rights

and Responsibilities On Hospital Portal → Refusal of

Treatment/Procedure/Service/ Test (AME-leaving against medical advice)


Error or Unexpected Event

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Subtopic 5.4.2.4



• If an Error or Unexpected Event Occurs (including Adverse Incident or Sentinel Event)

– Take care of the patient first

– Notify your supervisor and the physician

– Determine who will inform the patient and document disclosure in EMR

– Document the facts of the occurrence in the medical record

Do not document that an occurrence report was completed in the medical record

– Preserve and sequester all equipment and supplies involved (e.g., mislabeled medications, IV tubing, etc.) when applicable

– Call Risk Management ASAP at ext. 15899 or 772-288-5899 (note: Risk Management is available

after hours through the hospital operator)

– Complete an occurrence report via iReport before end of shift

Do not make copies

What to do: If an Error or Unexpected Event Occurs

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If you have a work-related injury, illness, or exposure:

1. Notify your leader at once

2. For blood/body fluid exposure, follow BLEX Quick Reference – Found on the MartinLink Occupational Health site under ‘Blood/Body Fluid Exposure

Guidelines’

3. Fill out an occurrence report (iReport) and seek treatment

a) In case of emergency, go to your nearest emergency room! Then follow the procedure described below.

b) Complete an Occurrence Report for your associate injury/incident as soon as possible (within 24 hours when possible )of injury (MartinLink iReport).

c) After filing out the report contact Occupational Health at 223-5945, ext. 14812 immediately to help coordinate your care.

d) If after 5pm or weekend/holiday: Call the hospital operator and ask for the on-duty nursing supervisor to help you coordinate your care. Follow up with Occupational Health, ext. 14812, the next business day.

Note: • Treatment must be authorized by Occupational Health. • Call Occupational Health for follow up. • All injuries must be reported. Failure to report your injury timely could jeopardize your benefits.

What to do: If there is a Work-related Injury, Illness, or Exposure

For additional information: On MartinLink → BLEX Quick Reference Contact Information: → Occupational Health ext.

14812

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Grievances 57

Subtopic 5.4.2.5



Patient Complaint vs. Grievance

Complaint

A complaint is: an issue that is unrelated to patient care.

Examples:

• Housekeeping of a room

• Food preferences

• Billing issues

Grievance

A grievance is: an issue that is related to patient care, but was not resolved by the staff that was present at the time of the issue. Examples: • Unmet patient care expectations • Premature discharge • HIPAA concerns • Lack of informed consent

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All written complaints are grievances (an email or fax is also considered a written complaint)

Please report grievances as soon as you receive them. The hospital must respond to grievances within a reasonable time frame (average of 7 days or less) and review, investigate, and resolve each patient’s grievance within a reasonable timeframe.

Patient Grievance

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• Grievances are handled by the Patient Experience Office and Risk Management

• Complaints that are made known after discharge from MHS services should be forwarded to the department director/manager and Risk Management promptly. These will be resolved according to the Risk Management grievance process standards.

• Patients have a right to file a complaint with the Agency for Health Care Administration. This information is included in the Patient Admission guide.

Filing a Grievance


Patient Grievances

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Reporting a Grievance

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Leader Patient complaints that occur while care is ongoing shall be forwarded immediately to the Manager, Charge Nurse, or Director of the area of service involved.

Chain of Command

Patient Experience ext. 14995 If unable to immediately resolve a grievance, please contact the Patient Experience office

iReport

If grievance occurs after discharge, then fill out an iReport.


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What MHS Does if an Occurrence Event Occurs


Topic 5.4.3

• Risk Management reviews every report and addresses the occurrence in one or more of the following ways: – Refer to department leader for follow up

– Education of associates

– Create or revise a policy or procedure

– Change a practice or process

– Reports are used to track and trend data

– Root Cause Analysis (RCA) may be initiated

– Failure Mode and Effects Analysis (FMEA)

What happens to Occurrence Reports?

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• A Root Cause Analysis (RCA)is done – In response to a Sentinel Event (required by Joint Commission) – When there is a serious adverse event or near-miss

• RCA identifies – Who was involved – Why something happened – How it happened – What can be done to prevent it from happening in the future

• People closely involved with the sentinel/adverse event, senior leaders, risk management, and others will be included in the RCA. You may be asked about the incident to help answer these questions.

Root Cause Analysis

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• A Failure Mode and Effects Analysis (FMEA) may be done to identify and prevent an issue before it happens.

• Goal: to reduce issues in a process/system and eliminate risks to patients, associates, physicians, and visitors – Identifies possible failures and how serious the failures are/

could be – Identifies how the failures occurred – Involves designing, testing, monitoring, evaluating, and

continually improving the process/system

• Every 18 months MHS is required (by Joint Commission) to look at a high risk process or system. – This helps ensure that MHS is constantly working to prevent

problems from happening. – This makes MHS a safer place for patients and associates

Failure Mode and Effects Analysis

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You have now reached the end of this module! • You can now review any content in this module by using the back button

or the Table of Contents on the left side of the screen. • This module will be marked as ‘Completed Unsuccessfully’ until you have viewed

each slide. You will not be able to proceed to the quiz until it is marked ‘Completed Successfully’.

Once you finish reviewing this module, you can return to iLearn to take the Module 5 Quiz. • Click the ‘X’ at the top right corner of the screen to exit the module

and confirm that you have reviewed all content and reference material. Then click ‘Exit and Finish’.

• The next activity that you will complete in iLearn will be the Module 5 Quiz. You can then start the quiz by clicking ‘launch’ in the list of activities.

Module 5 Complete!

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module 5: obligation to report - martinhealth.org · subtopic 5.4.2.1: adverse incident subtopic...

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