AGENCY GOALS

• Licensing and Renewal
  
• Investigation and Disciplinary
  
• Enforcement and Litigation
  
• Impaired Provider Programs
  
• Information and Education

INVESTIGATION AND DISCIPLINARY PROGRAM GOAL:

To promptly, aggressively and thoroughly investigate all matters alleging professional incompetence, unprofessional conduct and other statutorily proscribed conduct and to promptly submit completed investigations to review committees and advisory councils for fair and consistent recommendations.

OBJECTIVE #1:
To reduce average length of time from receipt of alleged violations until the investigation is complete. 

Strategies for Objective #1:

1. Utilize new FTE Public Service Administrator I authorized beginning July 1, 2007 to assist with department administration and review of specified categories of complaints.
2. Provide quarterly case reviews and oversight for each investigator to insure expected time frames are met and investigation are of a high quality.
3. Require each investigator to actively manage their caseload with the assistance of reporting capabilities now available in the enhanced computer operations installed during FY05.
4. Increase frequency of review committee meetings/advisory councils to insure quicker review of completed investigations.

Performance Measures for Objective #1:

OUTCOME MEASURES:

1. Use standard reports to monitor Investigator progress, and develop any reports to assist in this process as the need arises.
2. Continue to use new FTE Administrative Assistant to increase Investigator efficiency by permitting Investigators to delegate more administrative tasks.
3. Streamline investigations by providing continuing updates and training toI Investigators so they are more efficient in the field.

OUTPUT MEASURES:

1. Inform Investigator quarterly of their overall performance and compliance with established timeframes.
2. Investigator caseload reduced so that o no more than 10% of cases remain open after 180 days.
3. Commence investigations into 100% of all emergency situations not less than 24 hours following receipt of complaint.

OBJECTIVE #2:
Present completed investigations relating to standard of care issues to review committees/advisory councils promptly upon completion of investigation and receive fair and consistent determinations and recommendations from the committees/councils.

Strategies for Objective #2:

1. Present all cases that involve standard of care issues for the profession involved to the appropriate review committee/advisory council as soon as possible following completion of investigation-preferably not greater than 60 days after investigation complete. 
2. Utilize new FTE Public Service Administrator I to review completed investigations for completeness and assign case to appropriate review committee/advisory council or forward to disciplinary panel, thus insuring cases are complete when they are presented for review.
3. Provide all review committee and council members with hardware to read electronic data and continue to place all investigative files in electronic format.

Performance Measures for Objective #2:
OUTCOME MEASURES:

1. Use FY 05 enhancements to IT system to create reports that list the days between completion of an investigation and when it is presented to the appropriate review committee/council.
2. Create a fourth Medicine & Surgery Review Committee to insure MD cases are reviewed within 60 days of investigation completion.
3. Hold conference call meeting if a case is finalized for a profession with few investigations so that even a single case can be reviewed within 60 days without waiting for a full agenda of cases.

OUTPUT MEASURES:

1. All cases are presented to review committee/council within 60 days of completion of investigation.
2. Very few (5% or fewer) cases reviewed by a review committee/council that are sent back to the investigator for additional information that should have been anticipated and obtained prior to presentation for review.
3. Final Reports will include more detailed historical information on licensee to improve consistency in recommendations.

OBJECTIVE #3:
To ensure quality of investigations and adherence to established priority system in conducting all investigations.

Strategies For Objective #3:

1. Use enhancements obtained through IT project to generate reports reflecting cases reopened for additional investigation.
2. Use enhancements in IT system to create reports determining whether investigators are meeting stated time lines for completion of investigations based on the assigned priority level.

Performance Measures For Objective #3:

OUTCOMES MEASURES:

1. Increase to near 100% the number of cases that are complete and ready for review committee/council or disciplinary panel review upon finalization by investigator.
2. Investigation into Priority #4 cases will commence within 24 hours 100% of the time, and into Priority #3 cases will commence within 60 days 100% of the time.

OUTPUT MEASURES

1. Nearly 100% of cases finalized by the investigator will be complete and require no additional investigation after initial review.
2. Investigation into 100% of all emergency cases will be commenced within 24 hours and 100% of priority 3 cases will be commenced within 60 days.

OBJECTIVE #4:
To continue to fully enforce the Office-Based Surgery Inspection Program.

Strategies for Objective #4:

1. Further refine the efficiency of the Office-Based Surgery Inspection Program with the coordination of the new FTE Administrative Assistant funded in FY07 and made permanent in FY08.
2. Divide inspections evenly between each Special Investigator II, and assign cases based on geographic location of investigator, where possible.
3. Investigators will utilize office-based inspection manual and checklists in conducting all investigations.
4. Review findings of inspection at review committee within 60 days of completion.
5. Consult with the Office-Based Surgery Committee comprised of Board Members as soon as possible whenever an emergency or question requiring interpretation of requirements arises.

Performance Measures for Objective #4:

OUTCOME MEASURES:

1. Further refine skills of new FTE Administrative Assistant in coordinating Office-Based Surgery Inspection Program.
2. Analyze data obtained each renewal period to determine geographic concentration of licensees performing office-based surgery to evenly distribute inspections among each Special Investigator II.
3. Require that every office where surgery is performed by inspected at least every two years.
4. Provide findings of inspections to review committees to ensure standard of care is being met in all inspected offices.

OUTPUT MEASURES:

1. New Administrative Assistant will competently administer all organizational functions of Office-Based Surgery Program.
2. Investigators will become familiar with most offices of the licensees who perform office-based surgeries in their assigned geographic area.
3. Each Investigator will perform one-sixth of the inspections assigned per year.
4. Review Committees as well as the Board’s Office-Based Surgery Committee will provide guidance to ensure patient safety.  All regulatory violations will result in swift redress and/or discipline.

OBJECTIVE #5 (New)

To implement Legislative Post Audit’s recommendation and utilize new FTE Investigator I and new FTE Investigator II to investigate allegations of substandard patient care when they are received, rather than waiting for a pattern of such complaints to develop.

Strategies for Objective #5:

1. Establish a revised policy outlining the criteria that will trigger an investigation into cases involving a single allegation of a standard of care violation.
2. Utilize the two new FTE Investigators and identify if additional resources are required to fully implement this recommendation.
3. Create an additional Medicine and Surgery Review Committee to ensure all investigations are reviewed within 60 days of completion.
4. Review past complaints that were not investigated pursuant to policy as it previously existed to determine if investigations should be initiated based on revised policy and two additional investigators.

Performance Measures for Objective #5:

OUTCOME MEASURES:

1. Begin investigating allegations of a standard of care violation in all cases identified in the revised policy upon its adoption.  In the interim, investigate all patient complaints and Reports of Adverse Findings alleging a violation of the standard of care.
2. Measure additional work load that will be required of Special Investigators, support staff, and attorney staff.
3. Propose new Medicine and Surgery Review Committee members to Board for appointment.
4. If appropriate, investigate past complaints that were not investigated due to application of prior policy.

OUTPUT MEASURES:

1. Increase investigations to include all allegations of a violation of the standard of care as outlined in new policy.
2. Sufficient resources will be expended to ensure investigations are performed within the established timeframes.
3. Completed investigations will be reviewed by the appropriate review committee/council within 60 days of completion.
4. A review will be completed of old complaints not investigated that would have been investigated had the new policy been in effect and selected investigations initiated retroactively, where appropriate and where staff resources allow.