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Can you prevent harmful staff from getting hired?
Experts recommend anonymous reporting
(Editor’s note: This is the second article in a two-part series on preventing employees from harming patients intentionally. This month, we’ll give step-by-step instructions to prevent problem employees from being hired and tips to encourage staff to report concerns. Last month, we covered how to track deaths and improve communication with human resources.)
If a nurse, who had left a previous facility under suspicion of murdering several patients, applied for a hard-to-fill night shift at your organization do you think she’d be hired? Would it be possible for a technician to intentionally harm patients at your hospital over a period of years, with absolutely no action taken?
If you find yourself shaking your head in disbelief, consider the much-publicized killer nurses and physicians who eluded detection at many facilities, and you may feel differently. So what steps should be taken to ensure problem practitioners don’t fall through the cracks — and how can you prevent them from getting hired in the first place? Here are suggestions:
• Encourage staff to report suspicions.
As a quality manager, you need to draw upon the observations of staff throughout the facility, and encourage gut instincts to be reported, says Kathleen Catalano, director of regulatory compliance at Provider HealthNet Services in Addison, TX.
"In most instances, the quality manager learns of things only after the fact," she adds. "Education of the nursing staff is key, with a periodic review of what types of behavior to look out for, to avoid this scenario."
After a sentinel event occurs, a literature search is required in addition to a thorough internal investigation, Catalano notes. "Search the literature on this subject and glean from that the behaviors that fall into this type of scenario," she recommends.
For example, a red flag might be an individual who prefers to work with little help or interruption. "Most nurses want help and accept it gratefully. That’s a clue," says Catalano.
In general, nursing staff should share their suspicions with quality, risk, and human resources, she urges. "It is extremely important, in spite of everyone’s workload, that nonpatient care managers get out of their offices and know the staff working on the units, so that they aren’t intimidated about discussing possible suspicious behavior with them," Catalano says.
Similarly, the lines of communication must remain open between quality managers, human resources, and risk management, says Kathryn Baikie, the facility’s director of human resources. "Employees must feel they are able to confide in human resources professionals so that they can feel safe to blow the whistle on their co-worker if they see problems or issues, without fear of retaliation," she stresses.
• Follow all steps in a process.
Catalano points to the case of a physician who is believed to have killed more than 60 patients over a two-decade period.
"All of the things that should have been done were somehow missed," she says. "Even when processes were in place, they were not necessarily followed."
The scenario shows that if procedures aren’t followed to the letter, a harmful practitioner could slip through the cracks, Catalano warns. "Even if something that didn’t seem quite right showed up in the file, [the physician] would talk his way out of it," she says. "He was a master at this. The physicians decided there was no need to investigate further — he’s a physician, and we’ll take his word for it."
For this reason, Catalano strongly advises that each step in any process be followed, such as credentialing and privileging processes. "Disaster can lie right around the corner when you skip steps to save time," she says.
• Have an anonymous reporting system.
It’s a serious mistake to pin blame on the trend toward a nonpunitive patient safety environment, according to Catalano. "If the patient safety environment were punitive, you would never see anything reported by those in the trenches, because they would be afraid of losing their jobs. I can’t say that I blame them," she says.
There have been problems galore with punitive medication quality programs, Catalano adds. "I don’t believe blame can be placed on any one thing," she says. "Placing blame on no one and actually reviewing the entire process is the way to go."
For this reason, an anonymous reporting system is key, Catalano points out. "Staff often don’t want to rat on a colleague," she says. "With that in mind, put your anonymous compliance or patient safety hotline to work and be certain that retaliation does not occur when something is reported."
Still, the only way retaliation will no longer occur is if the facility enforces the nonretaliation policy that probably already is in place, says Catalano, who adds that this has to occur "from the top down. If even one person is found to be retaliating against someone for telling what they perceive to be the truth, that individual should be terminated or whatever the policy states."
The best system to use is a hotline allowing staff to report their concerns anonymously, she recommends. "The hotline must be outsourced and not a number called in-house. There must be safeguards in place for keeping the anonymity of the person. And there must be a system allowing the person making the call to check back and see what is being done regarding the reported issue."
The facility uses National Hotline Services, which gives the caller a number and a date to call back. "If action is taken, that action is reported back to the hotline, and they pass it on to the person if they choose to call back with their special number," Catalano says. "This works extremely well."
For instance, if a staff member calls to report the use of the wrong code for a certain procedure, an investigation would be initiated (including chart audits and a review of current law to see if changes had occurred and when the changes went into effect), and findings would be documented.
"If we found that coders had coded incorrectly, the hospital for which we were coding would be notified in writing with a complete breakdown of our findings," Catalano says. "They could, based on internal policy, notify the regional fiduciary intermediary. The results would be reported to the corporate compliance committee and on up the chain till it reached the board."
Education would be provided, and monitoring would be done to ensure that the situation did not recur, she points out. "Generally, when a hotline first is initiated, the main problem is people calling in with lots of HR issues. But that passes."
• Use a web-based information service to check disciplinary history of health care providers.
"In my opinion, the National Practitioners Data Bank (www.npdb-hipdb.com) does not provide enough timely information, and that makes it difficult to rely on," Catalano explains.
Instead, the organization uses the Fraud and Abuse Control Information System (www.facis.com.), a web-based information service that allows subscribers to look up the sanction history of individuals associated with the health care field.
"This is valuable, because it makes you aware of sanctions by the local, state, and federal government and adverse actions taken by various agencies," Catalano notes. "We have notice of any action that has been taken against a person at a state, local, or federal level."
All new prospective employees are screened through FACIS to be certain that they are not on the Office of Inspector General’s list of excluded individuals or entities, or the General Services Administration debarment list.
"If they were on either of these lists and we billed for services they rendered, we would be committing fraud," she adds.
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