Core Function 5: Reporting

Transcription

1 Core Function: Reporting 1 Core Function 5: Reporting Title Slide (music playing) Webcast Tips This webcast includes spoken narration. At the bottom of the viewing pane are the play and pause buttons as well as buttons to go back and forth. There are also buttons to adjust the volume and view the closed captioning. On the left is a table of contents that can be used to navigate to a specific area of the webcast. There are also times when buttons may appear on the screen. They will typically appear at the bottom. The webcast may pause until you click the button. To continue, click the Continue button that appears in the lower right hand corner. Certificates of Achievement will be available to Administrative Entity staff, Providers, Supports Coordinators, and SC Supervisors after completing all course requirements. Please view and then save or print your certificate in order to receive credit for this course. For SCs and SC Supervisors, course requirements include successful completion of a pre-test and post-test. Welcome Hello and thank you for viewing this webcast about risk management. My name is Ann Ligi and I work for the Office of Developmental Programs. I will be your narrator for this webcast. Webcast Focus In previous webcasts, the first four core functions of risk management were examined. This webcast will focus on reporting which is the fifth and final core function of risk management. This webcast will focus on why reporting is important as well as the areas to address in a risk management report. We will discuss the sections that are typically in an aggregate or system level report. There may be times, however, when a particular section such as an executive summary may not be appropriate to include in an individual level report and this will be pointed out as needed. You may be wondering why a report needs to be written. One reason is that it helps to communicate and document the actions taken, the results, and possible next steps. This is so we know what we have tried in the past and whether it worked or not. Also, it may be useful when a similar situation comes up for someone else. A report is also a way to show that the organization is taking steps to ensure the health and safety of those it supports and serves. You may not be responsible for writing the report, but it is beneficial to know the type of information contained in a report in case it can be applied to a situation in the future. As a member of the person s team, you have valuable information to contribute to the report. Reporting A report can consist of multiple sections, have a cover page, references, etc. or it can be as simple as a paragraph that describes the findings and next steps. The type of report that is written is dependent upon the situation, level of the report, individual or system, and who the report is going to be distributed to. You wouldn t want to give the Health and Welfare Committee of the House of Representatives a paragraph as a report, but a paragraph may be appropriate for a team meeting.

2 Core Function: Reporting 2 When a report is created is also dependent on the situation. A report is created according to its use, whether it is a formal or informal report, any regulation that establishes how often the report is completed, and of course, how often those receiving the report require it. For an individual, it would be appropriate to develop a brief report for a team meeting, updating the progress notes, prior to a monitoring visit, or the development of an ISP. Each time monitoring steps are completed, a report can be used to communicate the findings and next steps discovered through the monitoring activities. A report then communicates to others the findings, recommendations and actions to be taken. A report documents what was done, why it was done, and the results. This information is important to document because it tracks progress, identifies promising practices, provides evidence for accountability and transparency, and documents follow through. To put it simply, a report documents what was done so that there is a record of it. The Report Introduction A system level risk management report should contain the following sections: report description, executive summary, current status, process or methodology, data and information, findings, discussion, considerations and recommendations, and initiatives as a result of findings. The Report Title Page The first section of a report should include the title, organizational entity name, date, and frequency of the report. This information is typically on the cover page of the report. On the screen are two examples of system level reports. Take a moment to review them and then click [Continue]. In the monitoring webcast, we discussed Ivan and how he was having frequent falls. In response to the falls, the provider agency supporting Ivan completed a fall assessment and implemented various preventive strategies. The title page of a report about Ivan s falls might be what you see on the screen. Click [Continue] to go to the next slide. The Report Executive Summary The next section in a high level, formal report should be the executive summary. Even though this is the first content area of the report, it is the last one to be written once the findings and results are in. An executive summary provides high level details of the report or significant findings that gives the reader the highlights or themes of the report without having to read the entire report. A summary of next steps or recommendations would also be included. An example finding that may be included in an executive summary is Reportable incidents accounted for 52,322 or approximately 83 percent of all incidents. An executive summary would be included in reports that are larger in size. If the report is only two pages, most likely an executive summary would not be written. Think about the audience and whether an executive summary would be helpful based on the length of your report. The Report Writing the Report

3 Core Function: Reporting 3 As you write the report, keep in mind who the audience will be as various groups will have different knowledge bases and expectations. ODP s communications are intended to be accessible, straight-forward, and uncomplicated. If acronyms are used, be certain to spell them out and take advantage of graphics as well. You may even consider writing a simpler version of the same report conveying what does this mean to you? The Report Current Status Current status would be appropriate in an individual level report to indicate or describe how things are going. In Ivan s example, this is how many falls he s having and the impact, if any, of the preventive measures. Considering an individual level report using Ivan as an example, the current status might be something as simple as, we implemented the preventive measures a week ago and he has not had a fall. In a system level report, the current status could be a summary of year-to-date findings or could describe the status of a multi-phased initiative. Including the current status in the final report is optional, but if included should be related to the issue being reported. If you are reporting on a quality management or action plan to achieve improvements in mitigating or managing risk factors on a system-wide basis, it is important to state the current performance level and its relationship to the performance level to be achieved. Questions such as, Are we on track to achieve the intended performance objective by the target date? need to be integrated into the report. If it appears that the performance objective will not be achieved as originally intended, provide an explanation as to why not or what needs to be done in order to achieve the desired performance level by the target date. Any obstacles or challenges that were encountered should be stated and whatever actions that have been taken or will be taken to address them need to be included. The Report Process The process or methodology section includes a description of how the data was collected and analyzed, the incident review process, preventive measures that were implemented, etc. For Ivan, this section may have included information about the number of falls Ivan was having and that a fall assessment was conducted. Preventive measures were implemented so a description of what the implemented measures were, who was responsible, etc. should be included. If staff received training, that would be mentioned along with the training content, who did the training, who attended the training, etc. Also included would be how staff documented the falls, which in Ivan s case was through incident reporting. So this section contains all the details, the who, what, where, when, and how, about the steps that were taken to mitigate risk. The Report Charts and Data

4 Core Function: Reporting 4 The next section is where graphs and data are found. These are the results. In addition to graphs, there may be tables of data, graphics, pictures, etc. The intent of the data section is to summarize current results. For the report about Ivan s falls, the run graph would be included. Pictures of preventive measures that were implemented may be included as well. The Report Findings In the findings section, the results of data would be stated. Points that need to be considered for this section include: Putting the data in context of the most recent timeframes. Interpreting the findings and benchmarking the results if credible benchmarks are available. Describing the variation in the data and the type of variation. Pointing out any trends, clusters, patterns or cycles, as well as outliers. Adding graphs to clarify understanding of the data. For system level reports, it might be helpful to show the distribution of the data across levels such as by region, administrative entity, type of residence, waiver, etc. Statements such as The downward trend for the past several fiscal years reversed in May 2008 or A high frequency was reported for Misuse of Funds in November 2010 help to clarify the findings. The Report Discussion The discussion, one might say, is the core or meat of the report. It makes the results meaningful and helps to explain why the findings are what they are. Be sure to include information such as the following. How the data may be misinterpreted The cause, if known The relationship between the cause and the effect Any contributing factors The need for drill down or further review of specific details as determined by the findings. Relate the results to past and/or current efforts to remediate or improve the situation. And, refer to graphs and tables for specific categories and findings. Take a moment to read the statement on the screen which might be part of a discussion section. When you are ready, click [Continue]. The Report Recommendations The considerations and recommendations section is a discussion of factors that may influence findings, improve the process, better manage information or describe the context. A sample consideration is This was a pilot that was implemented incrementally and evaluated at each implementation step.

5 Core Function: Reporting 5 As a result of the findings, there are often recommendations made that are intended to make improvements, result in desired person-centered outcomes, or continue incremental quality improvement. These should be included in a section titled Initiatives as Result of Findings. This can take the form of training, new or revised policies, development, and commitment to new or expanded initiatives. An example initiative in an aggregate level report might be A mortality review report will be completed annually. The Report Managing Finally, reports need to be managed by keeping them on file or archived somewhere so they are readily accessible as necessary. Subsequent reports may build on them over time, so it is important to assure that in cases of staff turnover or changes in leadership, continuity is maintained. Remember, reports provide a way to know what actions were taken and the results of those actions which can be beneficial when faced with a similar situation in the future. Therefore, having a way to manage and easily access the content of reports is important. Thank You Thank you for viewing this webcast about the fifth core function of risk management, reporting. Please watch the next webcast in the series which ties all of the concepts in the previous webcasts together. (music playing) This webcast has been developed and produced by the Office of Developmental Programs Consulting System on behalf of the Pennsylvania Department of Public Welfare, Office of Developmental Programs.