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Management
Training Manual
July 2017
Risk Management Training Manual i
Table of Contents
Table of Contents
Section Page
Table of Contents i
Use of this Manual iii
Module I: Principles of Risk Management
Instructors Guide I-1
Learning Objectives I-2
Script for Instructor I-3
Power Point Presentation I-4
Handouts: Principles of Risk Management I-5
Elements of Effective Risk Management I-6
Module II: Risk Assessment, Evaluation & Planning
Instructors Guide II-1
Learning Objectives II-2
Script for Instructor II-3
Power Point Presentation II-4
Handouts: CDER Exercise Sample II-5
Risk Assessment & Planning Worksheet: Sample A II-6
Risk Assessment & Planning Worksheet: Sample B II-7
Risk Assessment & Planning Worksheet: Sample C II-8
Risk Assessment Inventory: Depression II-9
Risk Assessment Inventory: Falls II-10
Risk Assessment Inventory: Osteoporosis II-11
Risk Assessment Inventory: Physical & Nutritional Management II-12
Risk Assessment Inventory: Skin Breakdown II-13
Risk Assessment Inventory: Substance Abuse II-14
Consumer Profile Questions for Group Exercise II-15
Consumer Profile A: Annie II-16
Consumer Profile B: Bob II-17
Consumer Profile C: Cecilia II-18
Consumer Profile D: Donald II-19
Consumer Profile E: Ed II-20
Consumer Profile F: Felicia II-21
Module III: Risk Assessment, Evaluation & Planning Committee
Instructors Guide III-1
Learning Objectives III-2
Script for Instructor III-3
Power Point Presentation III-4
Handout: Title 17 Requirements for Risk Assessment, Evaluation & Planning III-5
Committees
Module IV: Special Incident Reporting
Instructors Guide IV-1
Learning Objectives IV-2
Script for Instructor IV-3
Power Point Presentation IV-4
Handout: Title 17 Requirements for Special Incident Reporting by Regional Centers IV-5
Title 17 Requirements for Special Incident Reporting by Vendors & Long-Term IV-6
Health Care Facilities
Incident Response Checklist IV-7
Risk Management Training Manual ii
Table of Contents
Section Page
Module V: Causal Analysis
Instructors Guide V-1
Learning Objectives V-2
Script for Instructor V-3
Power Point Presentation V-4
Handout: Preventative Action Checklist V-5
Module VI: Mortality Review
Instructors Guide VI-1
Learning Objectives VI-2
Script for Instructor VI-3
Power Point Presentation VI-4
Risk Management Training Manual
Introduction
This manual has been designed as a tool for regional centers to utilize in their staff
development and quality assurance efforts. Regional centers can utilize the training
modules for their own staff or as training opportunities for their vendors.
Structure
This manual is comprised of the following six training modules, each targeting a key
aspect of risk management.
Module Title
Module I Principles of Risk Management
Module II Risk Assessment, Evaluation & Planning
Module III Risk Assessment, Evaluation & Planning Committee
Module IV Special Incident Reporting
Module V Causal Analysis
Module VI Mortality Review
Cover Sheet
Instructors Guide
Learning Objectives
Script & Suggestions for Instructor
Power Point Presentation
Hand-outs
i
Options for Using the Material in this Manual
The material in this manual can be used in various ways. The manual in its entirety can
be used as a comprehensive curriculum in risk management. In addition, each module
can be presented as a stand-alone course. The handouts, including sample assessment
inventories and checklists, can be shared with staff to enhance their day to day work in
planning and coordination of services.
All of the materials in this manual can be tailored to any regional centers particular
needs. The instruments, forms, or tools incorporated in the modules are not mandated
for use by any regional center. They have, however, proven useful to many people in
service coordination, quality assurance, and staff development roles. Feel free to use
them and make them your own.
ii
Risk Management Training Manual
Principles of Risk Management
Module I
Module I
Instructors Guide
Course Outline
I-1
Risk Management Training Manual
Principles of Risk Management
Module I
Module I
Learning Objectives
I-2
Risk Management Training Manual 1
Principles of Risk Management
Module I
Risk Management is a term given to a set of practices that lead Ask the group what risk means to them. What are
to minimizing possible harm to individuals. In this instance, some common risks of everyday life for all of us?
individuals are persons with developmental disabilities who receive Use some common examples such as driving in
services through the regional centers. We will first examine risk traffic, family history of heart disease, cancer, or
management principles and discuss why risk management is high-risk behaviors such as riding a bicycle without
important.
a helmet or walking alone in unfamiliar
neighborhoods after dark.
In the second segment of this module, we will look at the specific
elements that should be present in an effective risk management
system.
While it may not be possible to totally protect individuals, a risk Distribute the Handout: Risk Management
management system seeks to identify factors that may increase Principles and review each principle.
those risks and actively promote practices that will keep risk as low
as possible.
Slide 1: Prevention of Serious Incidents is The Highest Start the Power Point or Overhead Projector
Priority Presentation.
If it is possible, we want to anticipate what risks may exist and Survey the group for examples. The following is
prevent them from happening. one example that you may use to begin the
discussion. If you experience a power outage,
Can you think of an example? These examples illustrate ensure that the food in the refrigerator is safe
interventions for risk factors that could be reasonably anticipated or before anyone grabs a snack and risks food-borne
identified and prevented. illness.
We all are responsible for looking out for risks and for doing what
we can to make environments safer.
Slide 3 (continued)
When an incident does occur, accurate and timely reporting is
essential. Reports must include who, what, when and where.
Accurate analysis of risk based upon complete information enables
us to develop sound person-centered strategies to prevent future
incidents.
Slide 4: Staff are Competent to Respond to, Report and Remind participants of the Tit le 17 requirements:
Document Incidents in a Timely and Accurate Manner Vendors are to report special incidents to the regional
center immediately, but not more than 24 hours after
learning of the occurrence of the special incident.
All regional center and vendor staff witnessing or learning of an Regional Centers are to report special incidents to
incident must report it in a timely and accurate manner. Training to DDS within two working days of learning of the
occurrence.
understand what to do when an incident occurs and how and
where to report it is key. Depending upon the roles of those in attendance, a
brief review of applicable regulations and statutes can
be included here. For example, vendors representing
Lets review the timelines for reporting. When should vendors
residential services licensed by Community Care
report special incidents to regional centers? When should regional Licensing, participants who work with children or who
centers report special incidents to DDS? work with persons who are elderly, etc.
Risk Management Training Manual 5
Principles of Risk Management
Module I
Slide 6: Risk Management Systems Should Emphasize Staff Survey the group on specific types of information
Involvement as Integral to Providing Safe Environments that direct support staff may have that others on
the individuals team may not. Examples may
Risk management is not just the job of management. The staff include such things as sleep and wakefulness
involved in any situation need to also be involved when it comes cycles, personal grooming habits, particular fears,
time to discuss future preventative actions or to help figure out how or behavioral changes during times of stress.
an incident could have been avoided.
With the goal of harm prevention, the experts are those closest to
the individual.
Slides 8 & 9: Effective Risk Management
of I-4
Risk Management
Prevention of Serious Incidents
is
2
Safe and Accessible Environments
are
Everyones Responsibility
3
Prevention of Serious Incidents
n Continuous Communication
n Accurate Reporting
n Report . . .
n Document . . .
A Quality of Life
6
Risk Management Systems
Should Emphasize Staff Involvement
as Integral to
7
Quality of Life Starts with:
with
8
Effective Risk Management
n Training of all involved in supporting individuals
with developmental disabilities in the risk
management process
serious incidents.
Staff are competent to respond to, report and document incidents in a timely and
accurate manner.
Individuals have the right to a quality of life that is free of abuse, neglect, and
exploitation.
Quality of life starts with those who work most closely with persons receiving
v A well-defined process for reporting incidents that is timely, complete, and accurate
v Immediate follow up and intervention to ensure health and safety and to mitigate
future risk
Module II
Instructors Guide
Additional Considerations: Due to the large number of handouts used in this session, the
trainer should count out and sequence them ahead of time to limit
interruptions during distribution.
Course Outline
A. Proactive Approach
B. Mitigation
C. Who Needs Risk Planning?
D. Assessment
E. Evaluation
F. Planning
Module II
Learning Objectives
II-2
Risk Management Training Manual
1
Risk Assessment, Evaluation and Planning
Module II
Mitigation is an important word in risk management. It simply Using the diabetes example, regular blood sugar
means reducing the likelihood of occurrence or recurrence of checks will mean that appropriate interventions are
situations or events. Mitigation strategies are essential taken to manage the disease before a person
components of the risk plan. These strategies may not totally reaches a crisis point.
prevent an occurrence but proactive interventions may diminish
the consequences.
Slide 4: Who Needs Risk Planning?
Any Special Incident Reports for the past year and note any
patterns.
Observe
What is the individuals behavior telling you? Do you see
things that cause you concern and may indicate that the
individual is at risk, such as withdrawal, tactile defensiveness,
avoidance of assistance with personal hygiene?
Once you have completed this risk assessment process, it is time 1. Distribute the CDER Summary handout. Discuss
to take the information and evaluate it to determine if significant the CDER as a tool that is available, contains a
risks are present and, if so, that effective risk mitigation strategies wealth of information, and is already in the persons
are in place. record.
Convene the Team 2. Give the group a few minutes to review the
Discuss with the consumer and team members what may document and then ask participants to identify risks.
constitute a risk for the individual. Base decisions on actual as
well as perceived risk. For example, living in a high crime 3. Responses should note such things as poor self-
neighborhood does not mean that you will become the victim of a care skills, incontinence, aggression, running away
crime. If you do not have good personal safety skills, however, behavior, and poor communication.
you may be at a greater risk than others in the same
neighborhood. 4. Now tell the group that this is a three-year-old
child. What seems like a significant risk with this
Balancing individuals rights, including the right to make choices, 1. Encourage participants to describe specific
with the potential risks that may be involved in the exercise of situations where they supported individuals in
these rights, can be a very difficult task. choices related to high-risk behaviors.
2. If the group needs prompting, ask participants:
Choice: Individual choice should be respected but it may be Have they ever worked with individuals who
necessary to probe to determine underlying causes for an engaged in high-risk behaviors?
individual making choices that are not in his or her best interest. 3. Prompt with examples such as: a person who
engages in unprotected sex; an individual who has a
Rights: Keep the consumers rights in mind and remember respiratory condition and smokes; a person who has
your responsibilities to consumers. Some things may not be easy a gall bladder condition and frequently eats greasy
Risk Management Training Manual 8
Risk Assessment, Evaluation and Planning
Module II
Worksheet Sample A
Worksheet Sample B
Risk planning will only be effective if all people who need to know Ask participants to suggest how to communicate the
about the Risk Plan follow it. For instance, if the risk assessment Risk Plan among all those involved with individuals,
identifies that the individual has difficulty swallowing, the team e.g., day program staff, respite providers, family
might decide that mealtime safety requires a staff member close
members who take individuals home for visits, etc.
by to respond if the person experiences problems while eating.
Anyone who assists with the individual when he eats must know
Participants may suggest communication logs that
this and be prepared to intervene appropriately. It must be clear
accompany the consumer between home and other
what the staff is to do and when. If the person attends a dance on
service sites, telephone contact systems set up by
Saturday night and refreshments are to be served, what should
the staff do? providers, regional center distribution of IPP sections
providing information on precautions, or
Use systems already in place to document training or individualized approaches and interventions.
communication of risk planning. Verify that the plan will actually
affect the identified risk. Solicit input from team members who
may not have participated in developing the plan.
Slide 14: Monitoring and Evaluation of the Plan
already in place. This would mean review of the Plan at the time
of quarterly or annual reviews. If Risk Plans are not part of the
IPP process, the team should establish a schedule for review.
1
Proactive Approach
n Risk Assessment and Evaluation
n Team Planning
n Monitoring of Plans
2
Mitigation
n Reducingthe Likelihood of
Occurrence or Recurrence
n Proactive
3
Who Needs Risk Planning ?
Anyone with an assessed risk, such as:
n Frequent SIRs
n Crises
n Interviews
n Observations
5
Evaluation
Who is at Risk?
Team Decisions
6
Planning
n Is there a Plan in place?
7
Risk and Responsibility
n Choice
n Rights
8
Documentation
n IPP Process
n Informal
n Formal
9
Risk Assessment Evaluation & Planning Worksheet (Sample A)
Individuals Name: Date of Discussion: Date of Note:
Participants:
Significant Risk Factors in the Persons Life - Are risks Description of the risk, Interventions required
List present? circumstances, frequency to eliminate or minimize
YES NO risk
1. Functional Status
a. Eating ? ?
b. Ambulation ? ?
c. Transfers ? ?
d. Toileting ? ?
2. Behavioral
a. Self-abuse ? ?
b. Aggression towards others or property ? ?
c. Use of physical or mechanical restraint ? ?
d. Emergency drug use ? ?
e. Psychotropic meds ? ?
3. Physiological
a. Gastrointestinal conditions ? ?
b. Seizures ? ?
c. Anticonvulsant meds ? ?
d. Skin breakdown ? ?
e. Bowel function ? ?
f. Nutrition ? ?
g. Treatments ? ?
4. Safety
a. Injuries ? ?
b. Falls ? ?
c. Community Mobility ? ?
5. Other ? ?
Instructions for completing the risk assessment worksheet: Under each specific area, list the Significant Risks identified. Indicate yes or no as to whether a
significant risk has been identified in the listed category. Indicate yes or no as to whether training/service plans are present for the specific risk. If training/service
plans have been developed, indicate the training/area. Briefly, indicate a summary of the intervention required to eliminate or minimize the risk. 10
Risk Assessment Evaluation & Planning Worksheet (Sample B)
Individuals Name: Date of Discussion: Date of Note:
Participants: 1. 2. 3. 4. 5.
Significant Risk Are risks
Factors in the present? Interventions required to
Persons Life - List eliminate or minimize risk
Description of the risk, circumstances,
YES N
frequency
1. Qualifying O
Developmental Disability
2. Other Disabilities /
Health Conditions
3. Special Conditions /
Behaviors
4. Skill Development
5. Other
11
Risk Assessment Evaluation & Planning (Sample C)
Name: Date:
Participants:
Documents Reviewed:
People Interviewed:
Plan:
Other Information:
12
Communication and Training
n Location
n Verification
13
Monitoring and Evaluation
n IPP Process
14
Outcome
15
Risk Management Training Manual
Risk Assessment, Evaluation and Planning
Module II
CDER SUMMARY
COUNSELOR: ______________________________________
DOB: ____________ AGE: _________ SEX: _____ PROG: _______ SECT:______ UNIT:_____
LGL STAT: ____________ S PARENT OR RELAT RESIDENCE: PARENT / REL
ETHNICITY: ____________ LANGUAGE: _____________
HEIGHT: ____________ WEIGHT:_____________
-------------------------------------------------------------------------------------------------------------------------------------------------------------
-QUALIFYING DEVELOPMENTAL DISABILITIES-
MENTAL RETARDATION: NONE
CEREBRAL PALSY: NONE
AUTISM: FULL SYNDROME
FACTOR: OTHER UNKNOWN AND UNSPECIFIED CAUSE OF MORBIDITY OR MORTALITY
IMPACT: MODERATE DATE: 1 / 02
EPILEPSY: NONE
OTHER TYPE OF DEVELOPMENTAL DISABILITY: NONE
--------------------------------------------------------------------------------------------------------------------------------------------------------------
-OTHER DISABILITIES / HEALTH CONDITIONS-
Indicate yes or no as to whether a significant risk has been identified in the listed category.
Indicate yes or no whether training/service plans are present for the specific risk.
Briefly, indicate a summary of the intervention required to eliminate or minimize the risk.
2
Risk Management Training Manual
Risk Assessment, Evaluation and Planning
Module II
Individuals Name: Stephen Anderson Date of Discussion: January 22, 2003 Date of Note: January 23, 2003
Participants: Steve Anderson, Brenda Smith (SC), Mary Anderson (Mother), Rhonda Johnson (Provider XYZ), Frances Mathers (Administrator)
Significant Risk Present Description of the risk, circumstances, frequency Interventions required to
Factors (List) Yes No eliminate or minimize risk
1. Qualifying
Developmental Disability
Seizure Disorder X Average of six seizures per year for the last four years; takes Plan developed (see IPP and
medication. Four of the last six occurred at night. quarterly notes). Interventions:
supervision, medication
monitoring, special diet,
consumer education, bed rails,
Medic-Alert bracelet. IPP
modified to include plans.
3. Special Conditions /
Behaviors
4. Skill Development
5. Other
Risk Management Training Manual
Risk Assessment, Evaluation and Planning
Module II
Indicate yes or no as to whether a significant risk has been identified in the listed category.
Indicate yes or no whether training/service plans are present for the specific risk.
Briefly, indicate a summary of the intervention required to eliminate or minimize the risk.
2
Risk Management Training Manual
Risk Assessment, Evaluation and Planning
Module II
Plan:
1. Stephen must never be alone in a situation where a seizure could risk his life (bathing); he
must be accompanied when traveling; (residence, day program, family).
2. Modify environment for safety: bed rails because 4/6 seizures occurred at night (residence).
3. Quarterly monitoring of blood levels of medications (Dr. Holmes-residence will document).
4. High protein diet as recommended by neurologist (home).
5. Consumer education to help Stephen make informed decisions about risks (day program).
Other Information:
Although Dr. Holmes strongly recommends the use of a helmet, Steve stated on January 21,
2003, that he would never get a girlfriend wearing one of those things. XYZ will provide
education about safety and helmets and will reevaluate Steves preferences in April, 2003.
Steve did agree to this education, to bed rails and to receiving the special diet. He takes his
medication independently and appears to understand the danger of being hurt if he is alone. He
said that he doesnt want to drown in the tub like his friend, and it is okay for staff to be near as
long as they dont watch him bathe.
Risk Management Training Manual
Risk Assessment, Evaluation and Planning
Module II
The following risk factors may be indicators of existing or developing problems. These should
be considered by the service coordinator, service provider, and other Team members when
assessing and planning for risk mitigation. Referrals for further evaluation by clinicians or the
regional centers Clinical Team may be needed to diagnose a specific condition or otherwise
address consumer risk. This inventory is not intended to take the place of a professional
diagnosis conducted according to accepted standards of clinical practice.
v if Risk Factor
Present
Loss of interest in things you used to enjoy, including sex
Feeling sad, blue, or down in the dumps
Feeling slowed down or restless and unable to sit down
Feeling worthless or guilty
Changes in appetite or weight (loss or gain)
Thoughts of death or suicide; suicide attempts
Problems concentrating, thinking, remembering, or making decisions
Trouble sleeping or sleeping too much
Loss of energy or feeling tired all of the time
Headaches
Other aches and pains
Sexual problems
Digestive problems (upset stomach, etc.)
Feeling pessimistic or hopeless
Being anxious or worried
Consumer: _______________________________________________Date_______________
Risk Management Training Manual
Risk Assessment, Evaluation and Planning
Module II
The following risk factors may be indicators of existing or developing problems. These should
be considered by the service coordinator, service provider, and other Team members when
assessing and planning for risk mitigation. Referrals for further evaluation by clinicians or the
regional centers Clinical Team may be needed to diagnose a specific condition or otherwise
address consumer risk.
History of falls
Previous falls resulting in a fracture or laceration
Frequent falls (two or more per month)
Impaired vision
Muscle or strength weakness
Gait or balance disorders
Dizziness or vertigo
Incontinence or frequent toileting
Agitation
Sleep Disturbance
Medications with known side effects that may affect balance or ability to ambulate
Orthostatic hypotension (dizziness upon standing)
Impaired mobility
Requires assistance with ambulation
Uses mobility equipment (wheelchair, walker, cane)
Foot or leg deformity
Seizures
Poor lighting
Wet or slippery floors
Loose electrical cords
Inappropriate footwear
Loose rugs
Other: specify _________________________________________________________
The following risk factors may be indicators of existing or developing problems. These should be
considered by the service coordinator, service provider, and other Team members when assessing and
planning for risk mitigation. Referrals for further evaluation by clinicians or the regional centers Clinical
Team may be needed to diagnose a specific condition or otherwise address consumer risk. This
inventory is not intended to take the place of a professional diagnosis conducted according to
accepted standards of clinical practice.
v if
Risk Factor
Present
Long term use of high dose corticosteroids
Heavy smoking (or passive smoking)
Heavy drinking
Immobility
Lack of sunshine
Low calcium intake
Other diseases
Family history of osteoporosis or fractures
Fracture after a minor bump or fall
Loss of height
Back pain
In women: Early menopause (before 45 years old)
Early hysterectomy (before normal menopause age of 50)
Irregular or infrequent periods during your lifetime
Consumer:_________________________________________________Date______________
Risk Management Training Manual
Risk Assessment, Evaluation and Planning
Module II
The following risk factors may be indicators of existing or developing problems. These should be
considered by the service coordinator, service provider, and other Team members when assessing and
planning for risk mitigation. Referrals for further evaluation by clinicians or the regional centers Clinical
Team may be needed to diagnose a specific condition or otherwise address consumer risk. This
inventory is not intended to take the place of a professional diagnosis conducted according to
accepted standards of clinical practice.
Physical Management
v if Present Risk Factor
Does the consumer have difficulty with gross motor skills such as walking or sitting?
Does the consumer have:
Contractures (severe joint tightness)?
Severe scoliosis and/or kyphosis (curvature of the spine)?
Windswept deformity of the legs (both legs fixed or pointed to one side)?
Severe muscle tightness (spasticity) or muscle weakness (floppy)?
Does the consumer maintain his/her head in a tipped back (hyperextended) position?
Has the consumer had problems with skin breakdown, redness that does not disappear
after 20 minutes, or skin breakdown that doesn't heal?
Does the individual have poor bladder or bowel control?
Nutritional Management
v if Present Risk Factor
Are there special dietary needs (i.e., caloric, consistency, texture)?
Has the consumer received modified food textures in the past (i.e., blended, chopped)?
Does the consumer need assistance to eat?
Does the consumer cough during meals?
Does the consumer have a history of choking?
Does the consumer frequently refuse certain types of foods or liquids?
Does the consumer eat in other than an upright position?
Does the consumer exhibit poor head control?
Does the consumer have a problem with:
poor lip closure and/or tongue thrust
bite reflex
gagging during meals and/or tooth brushing
rumination
excessive belching
frequent vomiting
persistent drooling
Has the consumer experienced dehydration in the past 12 months?
Does the consumer have history of nasogastric (NG) and/or gastrostomy (G) tube use?
Does the consumer tip his/her head back to swallow?
Does it take more than 30 minutes for the consumer to eat a meal?
Does the consumer have to swallow repeatedly to clear the mouth?
Has the consumer had any episodes of not breathing, turning blue, severe wheezing, or
pneumonia during the past year?
Is the consumer agitated during or after meals?
Does the consumer have reddened or whitened gums, visible film or plaque on the
teeth, or other significant dental problems?
Does the consumer not tolerate tooth brushing or being touched around the mouth?
Does the consumer eat rapidly; take large mouthfuls or too large bites?
Consumer: ____________________________________________ Date: _______________
Risk Management Training Manual
Risk Assessment, Evaluation and Planning
Module II
The following risk factors may be indicators of existing or developing problems. These should be
considered by the service coordinator, service provider, and other Team members when assessing and
planning for risk mitigation. Referrals for further evaluation by clinicians or the regional centers Clinical
Team may be needed to diagnose a specific condition or otherwise address consumer risk. This
inventory is not intended to take the place of a professional diagnosis conducted according to
accepted standards of clinical practice.
Inability to Move
Poor Nutrition
The following risk factors may be indicators of existing or developing problems. These should be considered by the service coordinator, service provider, and
other Team members when assessing and planning for risk mitigation. Referrals for further evaluation by clinicians or the regional centers Clinical Team may be
needed to diagnose a specific condition or otherwise address consumer risk. This inventory is not intended to take the place of a professional diagnosis
conducted according to accepted standards of clinical practice.
Frequent Intoxication
Does the consumer report or appear to be frequently high or intoxicated?
Do the consumers social activities focus on drinking or other drug use, including obtaining, using and recovering from use?
Has the consumer ever expressed his/her concerns about needing to cut down on use of drugs or alcohol?
Atypical Social Settings
Does the consumers immediate peer group encourage substance abuse?
Is the consumer socially isolated from others and is substance abuse occurring alone?
Is the consumer reluctant to attend social events where chemicals wont be available?
Intentional Heavy Use
Does the consumer use alcohol with prescribed medications?
Does the consumer use more alcohol than is safe in light of prescribed medications or compromised tolerance?
Does the consumer have an elevated tolerance, evidenced by use of large quantities of alcohol or other drugs without appearing
intoxicated?
Symptomatic Drinking
Are there predictable patterns of use which are well known to others?
Is there a reliance on drugs or alcohol to cope with stress?
Psychological Dependence
Does the consumer rely on drugs or alcohol as a means of coping with stress or problems?
Health Problems
Are there medical conditions which decrease tolerance or increase the risk of substance abuse problems?
Are there recurring bladder infections, chronic infections, bed sores, seizures, or other medical conditions which are aggravated by
repeated alcohol or other drug use?
Risk Management Training Manual
Risk Assessment, Evaluation and Planning
Module II
Risk Assessment Inventory
Substance Abuse (continued)
Job Problems
Has the consumer missed work or gone to work late due to use of alcohol or other drugs?
Problems with Significant Others
Has a family member or friend expressed concern about the consumers use of alcohol or drugs?
Have important relationships been lost or impaired due to substance abuse?
Problems with Law or Authority
Has the consumer been in trouble with authorities or arrested for any alcohol or drug related offenses?
Have there been instances when the consumer could have been arrested but wasnt?
2
Risk Management Training Manual
Risk Assessment, Evaluation and Planning
Module II
The following questions are presented for guidance to the group in its review of
consumer risk issues.
4. What resources can you access to obtain the assessment information you need?
Annie is a 20-year old woman who has mild mental retardation. Annies Aunt Nancy
served as her foster care provider from the time she was 12 years old until her 18th
birthday. Under the care of her aunt, Annie grew up very isolated with few friends or
opportunities to socialize with other children. Annies aunt was a very private person
who preferred time alone. She structured Annies time and contacts with others
accordingly.
When Annie turned 18, her aunt arranged for a residential placement in a licensed
community care home. She lives with three housemates. Since coming to the home
two years ago, Annie has had difficulties getting along with the other people living there.
She argues and starts fights with the other women. She has also become increasingly
verbally abusive to staff.
Annie smokes, and consistently breaks house rules about when and where she can
smoke. Smoking in her bedroom has created a safety risk for everyone and she has
started a fire in the waste can. Annie becomes quite upset when anyone mentions her
smoking habits as a problem.
The residential provider is very concerned about being able to meet Annies needs and
is seriously considering termination of her placement. This provider has contacted
Annies service coordinator for help.
Risk Management Training Manual
Risk Assessment, Evaluation and Planning
Module II
Bob is a 52 year old gentleman with a mild level of mental retardation. He receives
independent living services in his efficiency apartment. Bob has lived in a group home,
a supported living arrangement, and then on his own since he left a developmental
center ten years ago. Bob is passionate about his desire to remain living independently.
Bobs family has long advocated for him to return to the institution because they feared
he was not capable of living in the community, much less living in his own place. After
Bob had a stroke a few years ago, his family was even more convinced that he should
be living back at the center.
Since his stroke, Bob has had trouble negotiating uneven surfaces, navigating around
corners, and walking more than a block in his neighborhood. His speech is frequently
slurred and drooling has become a difficult problem. Bob becomes frustrated when
people cant understand what he is saying and, as a result, has begun to withdraw from
others. The drooling has also made him feel very self-conscious and embarrassed.
Bobs family has never stopped trying to convince him that he would be better off living
in an institutional setting. Bob is especially worried that they will be even more adamant
if they see the progressive problems he is experiencing with his speech and mobility. In
fact, hes getting concerned himself that he will not be able to live independently much
longer.
Risk Management Training Manual
Risk Assessment, Evaluation and Planning
Module II
Cecilia is a 47 year old woman who has a seizure disorder and severe mental
retardation. She lives with Rosa, her elderly mother, who has dedicated her life
to caring for her daughter. Rosa has resisted making any concrete plans for
Cecilia after her own death.
Cecilias mother has rarely sought any type of support or assistance. She always
tries to do everything herself, stating that she believes no one else can take care
of Cecilia as well as she can. Rosa also believes that Cecilia is her responsibility
until the day either of them dies.
Cecilia has become so overweight that she uses a wheelchair for mobility. Rosa
has injured herself several times lifting Cecilia and helping her with bathing, using
the toilet, and many other activities of daily living. Incontinence has also become
a problem with Cecilia, as has her recent diagnosis of osteoarthritis.
It has become increasingly difficult to care for Cecilia, yet Rosa has only
requested occasional respite services. Rosa herself has had numerous medical
problems including severe osteoporosis, diabetes, and rheumatoid arthritis.
.
Risk Management Training Manual
Risk Assessment, Evaluation and Planning
Module II
Donald is an older gentleman, age 62, who has Down Syndrome. He spent most
of his younger life in a state developmental center. He first lived in licensed
community care homes, and then received supported living services. For the last
15 years he lived with a roommate who passed away a few months ago. That
roommate, Philip, was Donalds closest friend and companion. A new roommate
moved in three months ago.
Donald has evidently fallen and hurt his foot. It has not healed and the wound is
filthy and in need of care. Donalds own hygiene also seems to be deteriorating
and his whole appearance has become disheveled.
Risk Management Training Manual
Risk Assessment, Evaluation and Planning
Module II
Consumer Profile E: Ed
Ed is a 25 year old man with severe cerebral palsy and a seizure disorder. Ed
uses a wheelchair for mobility. He can transfer himself but can not walk
independently.
Ed lives in a home with adults who also have physical disabilities. Ed only
recently moved to the home after his mother died. Until then, he lived in the
same hometown all his life, and had a close-knit group of friends, most of whom
do not have disabilities. Eds current residence is about 30 miles away from his
former home.
For the past several summers, Ed and his friends have gone camping at a spot
several hours drive away. Staff are quite concerned that this will be too risky for
him. Generally it is hot at these times and Eds anticonvulsant medicines can
sometimes make him very heat sensitive. The staff are also worried about his
capacity to move safely to, from, and around the campsite.
Ed is determined to go on this trip. Its a way to feel like he still has some of his
old life, but its also about feeling like he has some control in his new life. He has
begun to feel very angry.
Ed is adamant about going on this camping trip and wants his service coordinator
to advocate for him in this regard.
Risk Management Training Manual
Risk Assessment, Evaluation and Planning
Module II
Felicia is a 58 year old female with moderate mental retardation. She lived in a
state ICF/MR for more than 20 years and was placed there by her aging parents.
Felicia is currently living in a community care home and has been there
approximately six months.
Felicia has developed Type II diabetes shortly after entering the home and is
currently 50 pounds overweight. She has problems with poor eating habits. She
does not monitor her food intake or the types of food she eats. She has few
other activities during her day and equates pleasure with food and mealtimes.
Her diabetes is worsening.
Felicia has been exhibiting symptoms that her diabetic condition is progressing.
She is often fatigued, has dizzy spells and heals slowly when injured.
Risk Management Training Manual
Risk Management, Assessment and Planning Committee
Module III
Module III
Instructors Guide
Course Outline
III-1
Risk Management Training Manual
Risk Management, Assessment and Planning Committee
Module III
2
Risk Management Training Manual
Risk Management, Assessment and Planning Committee
Module III
Module III
Learning Objectives
III-2
Risk Management Training Manual 1
Risk Management, Assessment and Planning Committee
Module III
(b) (1): The Risk Management and Mitigation Plan shall address:
(b) (2): The Risk Management and Mitigation Plan shall address:
The provision of training and technical assistance to regional
center staff, vendors and long-term health care facility staff and
others on the legal obligations of abuse reporting, special
incident reporting, risk assessment, developing and
implementing an incident prevention plan, and proactive
accident/safety planning through the individualized program
planning process;
Some regional centers may want to review and revise their Ask for suggestions of additional topics or strategies that
curriculum or other resources to better reflect the implementation could enhance this area for regional center staff, vendors,
of specific risk management practices. and long-term health care facility staff.
Risk Management Training Manual 7
Risk Management, Assessment and Planning Committee
Module III
(b) (3): The Risk Management and Mitigation Plan shall address:
(b) (5): The Risk Management and Mitigation Plan shall address:
Slide 12 (continued)
4
Training & Technical
Assistance
Section 54327.2 (b) (2) requires:
6
Review of Special Incident Data
Section 54327.2 (b) (4) requires:
7
Medical Records & Coroner
Reports
10
Suggestions for Documentation
n Agenda
11
Benefits of Risk Management
Committee
(a) Each regional center shall establish a Risk Management, Assessment and
Planning Committee that, at a minimum, includes a representative from the
regional centers clinical, quality assurance and training staff.
(b) The Risk Management, Assessment and Planning Committee shall develop the
regional centers Risk Management and Mitigation Plan which shall address, at a
minimum:
(1) The process and procedures for ensuring accurate and timely handling
and reporting of special incidents by regional center staff, vendors, and
long-term health care facilities;
(2) The provision of training and technical assistance to regional center staff,
vendors and long-term health care facility staff and others on the legal
obligations of abuse reporting, special incident reporting, risk
assessment, developing and implementing an incident prevention plan
and proactive accident/safety planning through the individualized program
planning process;
(4) A process for reviewing individual and aggregate special incident report
data to identify trends and unusual patterns which may require regional
center action, and;
(1) Monitor the regional centers Risk Management and Mitigation Plan to
ensure it is being implemented;
(2) Annually review the regional centers internal special incident reporting
and risk management systems; and
(d) The Risk Management, Assessment and Planning Committee shall meet at least
semi-annually.
Authority: Section 11152, Government Code. Reference: Sections 4434, 4500, 4501,
4502, 4629, 4648, 4648.1 and 4742, Welfare and Institutions Code.
III-5
Risk Management Training Manual 1
Special Incident Reporting
Module IV
Module IV
Instructors Guide
Course Outline
IV-1
Risk Management Training Manual 2
Special Incident Reporting
Module IV
Risk Management Training Manual 1
Special Incident Reporting
Module IV
Module IV
Learning Objectives
3. Learn how to obtain and document all relevant information for an incident report.
IV-2
Risk Management Training Manual
1
Special Incident Reporting
Module IV
Special Incident Reporting is generally thought of as simply how Start the Power Point Presentation (or display first
to complete a Special Incident Report. While, of course, it is transparency on overhead projector). Have the Special
necessary to understand how to do this, it is not the intent of this Incident Reporting title page running as you begin.
session to present detailed information on how to complete each
blank on the form. Correctly completing the SIR form is only the
beginning.
During this session, we will spend time discussing how to write the
incident description portion of the SIR, as this forms the basis of
everything that follows. Without a good incident description we
will have problems later in reviewing the incident and in
developing appropriate preventative actions.
As service providers or regional center staff, it is imperative that If the regional center conducts specific training on
everyone understand what must be reported: recognizing and reporting SIRs, then refer to it now.
Any special incident as defined in Title 17 that occurs during the Differentiate between what is reported to DDS (Title 17)
time the individual was receiving services and supports from any and what else must be reported to the regional center.
vendor or long-term health care facility must be reported to the
regional center. Distribute copies of the following two handouts:
Requirements for Special Incident Reporting
The handouts now being distributed include all the specific by Vendors and Long-Term Health Care
requirements for Special Incident Reporting for both service Facilities; and
providers and regional centers. They serve as ready references as Requirements for Special Incident Reporting
you address special incidents in your day to day work with by Regional Centers.
consumers.
What are some of the reasons why incident reporting is Record these on a blackboard, marker board, flip chart,
important? or blank transparency.
Lets review a few of these reasons. Incident reporting systems: The reasons may differ from those listed in the script in
the left hand column; however, you should ensure that
Ensure accurate data is available to the region, the state, these are included. Add others on your own if not
and to CMS, the federal agency that monitors Medicaid volunteered by the group.
waiver services
Analyze and trend incident data from both an individual and
systems perspective for monitoring and improvement
To satisfy regulations
To meet our personal & professional responsibility
To provide a healthier and safer environment for everyone
we serve
Risk Management Training Manual
4
Special Incident Reporting
Module IV
Service Coordinators are faced with difficult decisions about how Ask participants how they report or receive reports of
much information should be included on the SIR. There is no special incidents and what information is typically
single, easy answer to this question that fits every situation.
included.
To know the correct answer, it is necessary to look at why the
Description of the Incident is necessary.
Another strategy is to read or display a description of a
special incident, and:
The purpose of this section is to objectively report the facts of an
(a) Have participants state what additional information
incident in as much detail as necessary to answer a few simple
they would want to know about what happened, OR
questions: Who? What? Where? When? In other words, enough
information should be provided to give important clues to the
actual circumstances of the incident. (b) Have participants tell the person sitting next to them
what they think happened. Ask a few people to share
Some history related to the incident may also be relevant (e.g. this their ideas as an illustration of how different people
is the third time the consumer has fallen at home in the past six interpret the details of the same incident differently.
months). Additional information should be added to the report as
it is obtained by the regional center. Reopening an SIR and
adding new information as it is received will lead to more fact
based conclusions.
Risk Management Training Manual
5
Special Incident Reporting
Module IV
As we have seen, the Special Incident Report should contain This section can be reinforced by having participants
sufficient information to answer the 4 W questions (Who? What?
review sample SIRs and critique how well these reports
When? Where?), but how much information is enough? When is
meet the Thorough-Accurate-Clear guidelines.
it too much?
Information should be included so the Special Incident Report is Another technique is to have participants tell what
thorough, accurate and clear. This means the words should draw information should be included based on an incident you
a mental picture of the circumstances surrounding the incident. describe.
Slide 6: Incident Description TIP If staff who have limited experience are in the audience,
you can include examples or have an activity requiring
Remembering these "tips" will provide guidance in determining participants to re-write inappropriately worded
what (and how much) information to include when reporting a statements. This activity can be done individually or in
special incident. The emphasis is to be factual. Include facts, as small groups. Sharing results at the end of the activity
you know them, giving the source of your information. Don't "go will allow opportunity for you to provide guidance and
beyond" the facts to make judgments. feedback.
Risk Management Training Manual
6
Special Incident Reporting
Module IV
Now that we have discussed the type of information needed to Hand out the Incident Response Checklist.
complete an SIR, let's talk about both the reporting of and
Give participants a few minutes to review it.
responding to special incidents. If you have had previous training
Ask participants to apply the checklist to one of the
on completing the SIR, you know the mechanics already - who
reports what type of incident, to whom do you report, what are incidents used in a previous example to become more
the required time lines, etc. familiar with this tool.
It is intended to be a useful tool to help everyone understand the For example, if the participants regional center(s)
expectations of reporting and responding to incidents regardless requires a phone or face-to-face contact between
of your job assignment. Although service coordinators have regional center staff and the consumer, discuss this
responsibility for ensuring that special incidents are entered into when reviewing the "ensure safety" step.
the SIR system, using this checklist will guide conversations
regarding incidents among reporters, service providers, regional
center staff and members of the Risk Management Committee.
In this session, we have reviewed why special incident reporting is This slide reviews previously presented information that
important and some basic information that should be included. can be used as a wrap-up or closure to the training.
Special incident reporting systems are critical to: You may also include other information that you feel
your audience needs to have reinforced.
Ensure accurate data is available to the region, the state, You may want to include a time for questions following
and to CMS, the federal agency that monitors Medicaid your closing.
waiver services
Satisfy regulations
The Process
IV-4
2
WHY Report Incidents?
To ensure accurate data is available
To analyze and trend incident data
To satisfy regulations
To meet personal and professional
responsibility
To provide a healthier and safer environment
3
The Incident
Who
What
Where
When
4
The Incident Description
Thorough
Accurate
Clear
Grammatical
5
Incident Description
Tips
EXPLAIN HOW INFORMATION
WAS ACQUIRED
Dont write as if you witnessed an incident
(unless you did).
Document what witnesses reported
(occurred/caused).
Dont draw conclusions or make judgments.
6
Incident Response
Insure safety Explore causes
Notify entities as Note necessary
required additions or
Check for corrections
completeness Track follow-up &
Inquire into completion
inconsistencies
Document details
7
WHY Report Incidents?
To ensure accurate data is available
To analyze and trend incident data
To satisfy regulations
To meet personal and professional
responsibility
To provide a healthier and safer environment
8
54327.1. Requirements for Special Incident Reporting by Regional Centers.
(a) The regional center shall submit an initial report to the Department of any special
incident, as defined in Section 54327(b) within two working days following receipt of the
report pursuant to Section 54327(b).
(b) When a regional center has knowledge of a special incident for which the vendor or long-
term health care facility is responsible for reporting but has not submitted a report to the
regional center within the required time period, the regional center shall submit an initial
report to the Department within two working days of learning of the occurrence.
(c) The initial report shall include the following information, to the extent the
information is available at the time of the initial report:
IV-5
Risk Management Training Manual
Special Incident Reporting
Module IV
(c) Any required information that is not submitted with the initial report in (b) shall be
submitted within 30 working days following receipt of the report of the special
incident pursuant to Section 54327(b).
(d) The regional center shall comply with all Department requests for initial and follow-up
information pertaining to a special incident.
(e) The report shall be considered complete when the regional center has submitted all the
information required by this section.
(f) Effective January 1, 2002, all reports of special incidents prepared by the
regional center shall be transmitted to the Department utilizing the Departments
Electronic Data Reporting System.
Authority: Section 11152, Government Code. Reference: Sections 4434, 4500, 4501, 4502,
4629, 4648, 4648.1 and 4742, Welfare and Institutions Code.
IV-5-a
2
ARTICLE 2. VENDORIZATION PROCESS
(a) Parent vendors, and consumers vendored to provide services to themselves, are exempt
from the special incident reporting requirements set forth in this Article.
(b) All vendors and long-term health care facilities shall report to the regional center:
(1) The following special incidents if they occurred during the time the consumer was
receiving services and supports from any vendor or long-term health care facility:
(A) The consumer is missing and the vendor or long-term health care facility
has filed a missing persons report with a law enforcement agency;
1. Physical;
2. Sexual;
3. Fiduciary;
4. Emotional/mental; or
5. Physical and/or chemical restraint.
IV-6
Risk Management Training Manual
Special Incident Reporting
Module IV
(c) The report pursuant to subsection (b) shall be submitted to the regional
center having case management responsibility for the consumer.
(d) When the regional center with case management responsibility is not the vendoring
regional center, the vendor or long-term health care facility shall submit the report
2
Risk Management Training Manual
Special Incident Reporting
Module IV
pursuant to subsection (b) to both the regional center having case management responsibility and
the vendoring regional center.
(e) The vendor's or long-term health care facility's report to the regional center
pursuant to subsection (b) shall include, but not be limited to:
(1) The vendor or long-term health care facility's name, address and telephone
number;
(2) The date, time and location of the special incident;
(3) The name(s) and date(s) of birth of the consumer(s) involved in the
special incident;
(4) A description of the special incident;
(5) A description (e.g., age, height, weight, occupation, relationship to
consumer) of the alleged perpetrator(s) of the special incident, if
applicable;
(6) The treatment provided to the consumer(s), if any;
(7) The name(s) and address(es) of any witness(es) to the special incident;
(8) The action(s) taken by the vendor, the consumer or any other
agency(ies) or individual(s) in response to the special incident;
(9) The law enforcement, licensing, protective services and/or other
agencies or individuals notified of the special incident or involved in the special
incident; and
(10) The family member(s), if applicable, and/or the consumer's authorized
representative, if applicable, who have been contacted and informed of the special
incident.
(f) The report pursuant to subsection (b) shall be submitted to the regional center by
telephone, electronic mail or FAX immediately, but not more than 24 hours after learning
of the occurrence of the special incident.
(g) The vendor or long-term health care facility shall submit a written report of the special
incident to the regional center within 48 hours after the occurrence of the special incident,
unless a written report was otherwise provided pursuant to subsection (e). The report
pursuant to this subsection may be made by FAX or electronic mail.
(h) When a vendor makes a report of an event to the Department of Social Services'
Community Care Licensing Division pursuant to Title 22, California Code of
Regulations, Section 80061(b) the vendor shall simultaneously report the event to the
regional center by telephone, FAX or electronic mail.
(1) The vendor shall concurrently submit to the regional center a copy of
any subsequent written report regarding the event that is submitted to the
Department of Social Services' Community Care Licensing Division.
(i) When a long-term health care facility reports an unusual occurrence to the Department of
Health Services' Licensing and Certification Division pursuant to Title 22, California
3
Risk Management Training Manual
Special Incident Reporting
Module IV
Code of Regulations, Sections 72541, 75339, 76551 or 76923, the long-term health care
facility shall simultaneously report the unusual occurrence to the regional center
immediately by telephone, FAX or electronic mail.
(1) The long-term health care facility shall concurrently submit to the
regional center a copy of any subsequent report, or any written
confirmation of the unusual occurrence, that is submitted to the Department of
Health Services' Licensing and Certification Division.
(j) The vendor or long-term health care facility may submit to the regional center a copy of
the report submitted to a licensing agency when the report to the licensing agency contains all the
information specified in subsection (d)(1) through (10).
(k) These regulations shall not remove or change any reporting obligations under the Elder
and Dependent Adult Abuse Reporting Act commencing with Welfare and Institutions
Code Section 15600 or the Child Abuse and Neglect Reporting Act commencing with
Penal Code Section 11164.
Authority: Section 11152, Government Code. Reference: Sections 4500, 4501, 4502, 4648,
4648.1 and 4742, Welfare and Institutions Code.
4
Risk Management Training Manual
Special Incident Reporting
Module IV
Incident Response Checklist
The following steps will assist you to respond when a report of a special incident is received.
The steps on the left are intended to guide you through the process. The strategies on the right
are suggested guidelines for completing each step. Not all strategies will be applicable in every
situation. Code Strategies as follows: Y = Yes, N = No, NA = Not Applicable.
Causal Analysis
Module V
Instructors Guide
Course Outline
V-1
Risk Management Training Manual
Causal Analysis
Module V
Causal Analysis
Module V
Learning Objectives
strategies.
V-2
Risk Management Training Manual 1
Causal Analysis
Module V
Causal Analysis
We know from our work in services for people with developmental In this example, you want to make the point that most
disabilities that rarely, if ever, does any one thing cause an incidents have more than one cause, and that at times,
incident to occur. Generally, incidents occur because of a those causes are inter-related.
combination of different factors. It is this unique combination of List on a flip chart all the possible causes volunteered by
factors that results in an accident, illness, or injury. Think about participants. These may include: Mary was dizzy when
causal analysis as "peeling an onion" to reveal all contributing she stood up due to blood pressure problems, Mary has
causes to an incident. In order to develop appropriate an ear infection that affected her balance, Mary's
preventative action that will lessen the likelihood of the incident roommate had spilled something on the floor, the
recurring, contributing causes need to be examined. overnight staff moved Mary's shoes and she tripped, etc.
Are any of you aware of an incident that, within a short time, List these examples on a flip chart you can refer to
reoccurred with the person or happened to another person in a
during later discussions of preventative action.
similar situation?
Examples may include falls in the same location of the
day program, choking on food that was not prepared
Causal analysis is a way to be proactive when an incident occurs.
When we are reactive, we simply react to what has happened: according to texture modification requirements, being
We report the incident to the appropriate people and complete the injured repeatedly by a house mate who has assaultive
necessary paper work. behavior, etc.
With the causal approach, we may still address those things, but
we don't stop there. We ask "Why" the incident happened, what
contributed to the incident happening, and how could it have been
prevented.
Lets apply these steps to a situation involving a consumer named Lead the group, step by step with questions regarding
Maria and a staff member named Sue. the scenario of Maria being injured.
When the primary cause is mentioned, (e.g., Maria was
One evening while Sue was helping Maria take a bath, Sue left the left unsupervised in the bathroom), ask "WHY?" to
bathroom briefly to get a towel. When she returned, Maria was encourage participants to go deeper into the situation.
lying on the floor bleeding from a large cut on her head. For example: Maria was unsupervised because Sue did
not get the towel first. WHY? Because Sue was
distracted and did not prepare completely. WHY?
Because there was another emergency going on at the
same time. WHY? Because Sue was going to help
Maria bathe while another staff person was on break.
These Common elements are factors that typically contribute to Following the review of this slide, it will be important for
special incidents. To complete a causal analysis and determine participants to practice reviewing an incident to arrive at
the contributing factors, each of these should be considered. causal factors.
Staff: Available staff, tenure, training, competency level, and A way to do this is to have them review an incident,
experience.
either individually or in groups. The above incident on
Consumer: Medical status, functional ability, cognitive level, Maria can be used, as well as an incident volunteered by
behavior, physical ability, needs, and preferences.
one of the participants.
Communication: Communication systems between
consumer, family, providers, staff, shifts, supervisors,
One way to structure this activity is to have each of the
disciplines, information, and availability.
factors listed on a sheet of paper and have the
Equipment: Needed, available, working, and in need of
participants list what about that factor "caused" or
adaptation.
contributed to this event.
Policies: Policies in place, known, followed, and effective.
Environment: Life Safety Code violations, cold/hot, noise It is important to point out that discussing common
level, distractions, light/dark, modified, and distractions.
factors may result in the participants realizing that they
Leadership: Supervision, training, oversight, and do not have all the facts and that they have to go back
organizational support for a culture that focuses on health and
to fact finding.
safety.
Risk Management Training Manual 8
Causal Analysis
Module V
Slide 8 (continued)
Analysis V-4
Causal Analysis
The most basic reason(s)
for an undesirable
condition or problem
Purposes of Cause Analysis
3
Traditional or Cause Analysis
4
A 12 Step Process
1) Involve appropriate 7) Complete analysis
people 8) Ask WHY questions
2) Review facts 9) Determine
3) Determine primary contributing causes
cause 10) Develop
4) Brainstorm potential preventative action
contributing factors 11) Obtain leadership
5) Identify barriers support
6) Check common 12) Monitor results
factors
5
Possible Common Factors
n Staff n Equipment
n Consumers n Policies
n Communication n Environment
Systems
n Leadership
6
Advantages of Cause Analysis
n Standardized process
7
Preventative Action
n Identifies situations where corrective
actions are needed
8
Preventative Action Checklist
n Focuses on outcomes
10
Causal
Analysis V-4
Causal Analysis
The most basic reason(s)
for an undesirable
condition or problem
Purposes of Cause Analysis
3
Traditional or Cause Analysis
4
A 12 Step Process
1) Involve appropriate 7) Complete analysis
people 8) Ask WHY questions
2) Review facts 9) Determine
3) Determine primary contributing causes
cause 10) Develop
4) Brainstorm potential preventative action
contributing factors 11) Obtain leadership
5) Identify barriers support
6) Check common 12) Monitor results
factors
5
Possible Common Factors
n Staff n Equipment
n Consumers n Policies
n Communication n Environment
Systems
n Leadership
6
Advantages of Cause Analysis
n Standardized process
7
Preventative Action
n Identifies situations where corrective
actions are needed
8
Preventative Action Checklist
n Focuses on outcomes
10
Risk Management Training Manual
Causal Analysis
Module V
Steps Strategies
Does the action address the cause of ___ Have all who, what, when, and where questions been answered?
the incident? ___ Does the incident description adequately depict what happened?
___ Could the incident occur again?
___ Is more than one explanation possible for what happened?
Have prior data and documentation ___ Has there been a record review?
been analyzed to determine any ___ Have there been documented skills deterioration, sleep disturbances,
possible contributing factors? changes in eating habits, or changes in medication?
___ Have there been changes in events, stressors, and/or noise levels?
___ Has the person been a victim of abuse or neglect?
___ Can you identify any related patterns (employees, place, times of day,
setting conditions, other consumers, etc.)?
___ Have environmental issues been identified and corrected?
Does the preventative action plan ___ Is it measurable?
include specific actions? ___ Are timelines for preventative action included?
___ Does the preventative action plan include the responsible person(s) and
actions needed to be taken?
Are the preventative actions doable? ___ Are noted actions within the control of the service coordinator, regional
center, and/or provider?
___ Are necessary resources available?
___ Does the responsible person have the authority to implement prescribed
actions?
Can it be monitored? ___ Is there a clear and objective system in place to monitor the
implementation and effectiveness of the preventative action plan?
If the preventative actions are ___ Have past preventative actions been effective in reducing risk?
implemented, can they prevent the ___ Have all elements of previous preventative action plans been
incident recurring? implemented?
If the incident involved an ___ Was the action implemented and documented?
environmental factor, was it rectified?
If the incident was linked to a ___ Has the program been reviewed and revised as necessary?
programmatic issue, has the person ___ Are any revisions documented?
responsible for the training program V-5
been notified and involved?
Risk Management Training Manual
Causal Analysis
Module V
Risk Management Training Manual 1
Mortality Review
Module VI
Mortality Review
Module VI
Instructors Guide
Course Outline
VI-1
Risk Management Training Manual
Mortality Review
Module VI
Mortality Review
Module VI
Learning Objectives
VI-2
Risk Management Training Manual 1
Mortality Review
Module VI
Mortality Review
Slide 7: How are Mortality Reviews Conducted? Ask participants currently involved in mortality reviews
to discuss their procedures. You might ask for
Several methods may be used to complete the review process. It is strategies they think work well in their system or for
suggested that, prior to the meeting, each committee member
areas they think could be enhanced.
reviews the facts surrounding the events to be reviewed.
trends in planning;
use of resources;
deviations from normal health status; and,
limitations or failures of support.
Risk Management Training Manual 6
Mortality Review
Module VI
Slide 7 (continued)
It is also recommended that representatives of the regional center Ask participants who serves on their committee, if
management team such as a service coordination supervisor and committees are currently being used in their
quality assurance supervisor be included. organization.
Slide 10: Information Dissemination Ask participants what happens to the findings from
these reviews. If mortality reviews are not used, have
Following the review process, recommendations for improvement participants list those who should receive, or could
should be compiled and shared across the entire system. Regional benefit, from this information. Lead a discussion on
centers will need to consider methods of information dissemination, how sharing could be done without compromising
paying particular attention to confidentiality issues related to the confidentiality. Possible solutions could be to: share
decedents and their families, vendors, and others involved in the aggregate results to supervisors such as the number
persons care and treatment. of reviews completed, number and type of
recommendations, information available for review,
etc.; making aggregate data (altered for
confidentiality) available for review by appropriate
parties; composing fictitious accounts based on actual
reviews that could be used for training.
Slide 11: Potential Challenges
Slide 11 (continued)
2
Organizational Support
n Culture
n Cross-disciplinary team
approach
3
Purposes of Mortality Review
4
Designing the
Mortality Review System
n Why Conduct Mortality Reviews?
5
Why Conduct a Mortality
Review?
n Outcomes
n Recommendations
6
How?
n Collect Information
n Propose Recommendations
7
When are Mortality Reviews
Conducted?
Triggers from Special Incident Reports
8
Who?
n Clinical Staff
9
Information Dissemination
n Recommendations Shared
n Confidentiality Ensured
10
Potential Challenges
n Sufficient information available
n Timely notification
11
Mortality
Review
System-Wide
Quality Enhancement