Critical incident reporting. Washington State Health Care Authority contract requirements and Amerigroup Washington, Inc.

Transcription

1 Critical incident reporting Washington State Health Care Authority contract requirements and Amerigroup Washington, Inc. reporting process WAPEC November 2018

2 Outline Critical incident overview o What is a critical incident? o Health Care Authority (HCA) contract requirements o Who must report? Reporting requirements o Incident categories o Timeline o Critical Incident Report Form instructions o Incident closure 2

3 Critical incident overview: What is a critical incident? Definition Unexpected event or situation with significant impact on the health and/or safety of our members or contracted agencies and facilities Contract Washington State Health Care Authority lists specific critical incident categories that are monitored and reported to them This training Focuses on HCA contract reporting requirements; Other events impacting health/safety may be reviewed clinically and monitored separately 3

4 Critical incident overview: HCA contract requirements MCO development of a Critical Incident Management System: o List of critical incident categories o Minimum required information to be reported o Timeline expectations for reporting o Biannual summary report instructions Analysis of incident trends by category, region and demographics Review of effectiveness of Critical Incident Management System, including summary of prevention and follow-up activities Recent changes to streamline processes o One category list versus separation of physical health/behavioral health o One HCA reporting method through Incident Reporting System 4

5 Critical incident overview: Who must report? Contracted provider network o Individual providers o Staff members of provider agencies, clinics or facilities o Subcontracted or delegated service entities o Across all Amerigroup covered services and programs Amerigroup internal staff o If an event is identified during course of business o If a member reports the event to Amerigroup staff 5

6 Incident categories Homicide or attempted homicide by an enrollee The unexpected death or serious injury of an enrollee o Sudden death, under unusual circumstances, suicide, etc. o Serious injury resulting in medical attention, including suicide attempt Abuse, neglect or exploitation of an enrollee Violent acts allegedly committed by an enrollee o Arson, assault resulting in serious bodily harm, homicide or attempted homicide by abuse, drive-by shooting, extortion, kidnapping, rape, sexual assault or indecent liberties, robbery, or vehicular homicide Unauthorized leave from secure facility Event that is likely to attract media attention 6

7 Timeline Critical incident occurs Amerigroup Critical Incident Manager (CIM) is notified of incident within one business day of awareness using Critical Incident Report Form Critical incident is reported CIM enters incident into Incident Reporting System to HCA within one business day of receipt of Critical Incident Reporting Form Critical incident is closed CIM completes investigation and follow-up actions within 45 days to close the incident in the Incident Reporting System 7

8 Critical Incident Report Form instructions Completed and submitted by secure to in word document format within one business day of awareness of incident. CIM may contact reporter to request additional details to assist in investigating and closing the incident. 8

9 Critical Incident Report Form instructions (cont.) Date/time of incident If known Location of incident Must be where the incident occurred o Member residence, facility, other locations, community or unknown Treating provider If relevant to the incident o Medical services resulting from incident, or ongoing services following Incident description Objective, factual and relevant details 9

10 Critical Incident Report Form instructions (cont.) Select all appropriate categories Use Other if member-related incident is not listed, or for facility, agency or community-related incidents Media Interest is often in addition to another category 10

11 Critical Incident Report Form instructions (cont.) Leave blank if there are no specifically identified persons o Facility or community incidents, natural disaster, etc. All identifiable persons directly involved in the incident o Primary Person vs. Secondary Person clarification on next slide o Person Type and Category clarification on slide 13 11

12 Critical Incident Report Form instructions (cont.) Do NOT send identifying information of other MCO s members. Primary Person Identified person most directly involved o Amerigroup member Secondary (and additional) Person Any other identified person(s) directly involved in the incident o Report the secondary and additional persons with as much information as possible Minimum necessary if other MCO s member (description of involvement only) o If cannot be identified or a large group of others were involved, include a description of involvement in the incident description section 12

13 Critical Incident Report Form instructions (cont.) Drop-down menus include the following: Person Type: Who are they? Client Member Other Patient Resident Staff Visitor Person Category: How are they involved? Alleged perpetrator NA Perpetrator Victim Witness 13

14 Incident closure Initial report Critical Incident Manager (CIM) verifies incident details and involved persons Investigation CIM reviews circumstances and events leading to incident, and potential care gaps or other missed prevention opportunities Closure CIM coordinates necessary follow-up to incident with provider network, care management, or other services and verifies member s current status 14

15 Conclusion and questions For additional questions or clarification, please contact the Quality Management critical incident inbox at 15

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