SITUATION MANAGEMENT TEAM CHARTER - Template
Purpose:
The team is responsible for assuring that timely and thorough investigation, intervention,
and reporting occurs as a result of all potential and actual significant events which occur
at the Kaiser Permanente XX Medical Center. This team will also meet regularly and
monitor progress of programs implemented as a result of interventions through the Risk
Management Patient Safety (RMPS) Committee. Significant event management will be
conducted according to policy
Authority:
The Quality Committee has granted the SMT its authority to direct medical center entities
to implement new, or change existing, practices designed to enhance patient safety and
reduce risk of harm.
Scope of Work:
The scope of the committee is to increase patient safety and reduce patient harm
associated with the delivery of health services in all settings of care while indirectly
reducing the events, member complaints, and medical legal claims that can result from
this harm.
Reporting Structure:
The team reports through the Risk Management Patient Safety Committee with regular
reporting through the quality structure.
Priorities and Objectives:
Sponsor and direct risk prevention/patient safety strategies/projects,
Monitor effectiveness of strategies/projects,
Communicate high risk/patient safety patterns, priorities and projects to facility
leaders local Quality Committee
After identification of a potential event:
Investigation – determine the benefit of establishing a multidisciplinary
workgroup to facilitate investigation. Identify stakeholders from affected clinical
area, and facilitate the investigation, which includes interviewing all staff that
were directly involved in the event.
Ensure prompt and proper care of a patient who has been affected by an event
Situation Stabilization – Immediate actions to reduce the likelihood of further
occurrences, i.e., discontinuing use of and removing faulty or suspect equipment,
sequestering suspect medications, or initiating interim procedural safeguards.
Preservation of Evidence – such as documents to insure an effective analysis and
record of the occurrence. Appropriate actions may include obtaining statements
Developed: 2/05; Revised: 12/05
SITUATION MANAGEMENT TEAM CHARTER - Template
from witnesses, securing medical records and/or biological specimens,
sequestering suspect medications and suspect medical equipment
Assessment of need for additional follow-up actions with staff and practitioners
including decisions for administrative leave pending investigation for errors that
are caused by an employee under the influence of drugs or alcohol; has
deliberately violated rules or regulations; specifically intended to cause harm; or
engaged in gross or egregious conduct.
Develop a chronology of relevant history
Complete Event Investigation Worksheet
Assist with Root Cause Analysis as appropriate
Monitor interventions and plans of correction – periodically review the plans of
correction and outcome measurements for significant events (through the RMPS
Committee).
Structure:
Decisions to be made by consensus of at least a quorum of the membership
A quorum is defined as one half of the membership
Contemporaneous minutes to be taken.
Frequency of meetings:
The team will meet weekly. After-hours, in response to a potential or actual event, the
Administrator On-Call is responsible for notifying members of the team.
Annual Evaluation:
Evaluation of structure/function of committee and sub-committees, including
membership and charter
Effectiveness of activities, projects, goals and priorities, as well as determination
of barriers encountered, and the setting of goals and priorities for the following
year.
Confidentiality:
All Situation Management Committee and subcommittee minutes, reports,
recommendations, memoranda, and documented actions are considered quality
assessment working documents and are kept confidential. They are maintained in
accordance with policies and procedures, and are privileged and protected from discovery
under statutes related to quality improvement/quality assessment and peer review. All
records are maintained in a manner that preserves their integrity, in order to assure that
patient and practitioner confidentiality is protected. All staff receive training on
confidentiality at the time of hire and annually thereafter.
Developed: 2/05; Revised: 12/05
SITUATION MANAGEMENT TEAM CHARTER - Template
Membership:
The team is co-chaired by Risk Physician leader and the Director of Risk
Management/Patient Safety.
Members:
Chief Quality Officer
Nurse Executive
Quality Physician leader
Chief Operating Officer
Assistant Chief of Quality
Medical/Legal Chief
Assistant Medical Group Administrator Risk/Quality
Director of Nursing Practice
Ad Hoc members:
Director of Quality
Director of Member Services
Director of AR&L
Public Affairs Leader
Health Care Ombuds/Mediator (HCOM)
other individuals as dictated by case specifics.
Developed: 2/05; Revised: 12/05
COMMUNICATING
UNANTICIPATED
ADVERSE OUTCOMES
Situation Management Team Roles and Responsibilities
ADVISE: To serve as a consultant to the clinicians, staff and administrators involved in
an adverse outcome in order to help them identify and work through the key issues that
these situations involve.
COACH: To allow the opportunity to think through and practice responses to the
patient and family in order to build and deliver a response consistent with our principles.
This could include role-playing to get words, voice tone and body language that are
appropriate to the disclosure situation at hand and that anticipate the turns and
challenges that may emerge in the discussion.
COUNSEL: To assist the clinicians, staff and administrators in the emotional distress
that often accompanies these adverse outcomes and the disclosure situations. This may
include arranging for most effective resources or providing the counseling itself to the
extent one feels trained and able.
FACILITATE: To attend the meetings among clinicians, staff and administrators and
with patients and families to moderate the discussion, to assist in promoting an honest,
empathic and sensitive discussion of the issues and to help set and enforce safe
boundaries for the discussion for all parties involved. This will involve helping to set up
pre-meeting ground rules as well as helping to guide the discussion as it actually takes
place.
COORDINATE: To recognize and follow-up on the tasks that emerge from disclosure
situations and which may require involvement from multiple clinician, staff and
administrative departments interacting with the patient and family over a longer period
of time.
SERVE AS OMBUDSPERSON: To be a person to whom anyone involved in the
disclosure process can go to express concern and who will take responsibility to see that
these concerns get acknowledged and addressed as the process goes forward.
Ombudsperson intervenes early and resolves issues at the lowest level possible, involving
the least number of individuals.
COMMUNICATING
UNANTICIPATED
ADVERSE OUTCOMES
Implementing the “Communicating Unanticipated Adverse
Outcomes” Program
—A Roadmap To Help Guide the SMT—
1. Program Purpose and Goals
2. Assessment of Current Process / Performance (Including Strengths and Gaps)
3. Key Players — Who’s going to get you there ?
A. Program Sponsor(s)1
B. Program Champion(s)2
C. SMT Members
D. SMT Partners
E. Others:
1 Your sponsor should be able and willing to establish and communicate the context and rationale for your project,
create commitment, allocate resources, participate in goal setting, monitor progress, and align reward and recognition
systems
2
Your champion should be tenacious, credible, flexible, empowering, communicative, results-oriented, organized, and
motivating. Of all these, credible may be the most important.
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COMMUNICATING
UNANTICIPATED
ADVERSE OUTCOMES
4. Program Elements Requiring Planning
A.
B.
C.
D.
E.
F.
G.
H.
Policy/Procedure
Roles and Responsibilities
Resource Planning
Education and Training
Reporting Process
Response Mechanism
Monitoring Function
Organizational Learning and Sharing
5. How Will You Know You’re Succeeding? Developing A Local Measurement Strategy
It may be helpful to think in terms of the following:
What question are you
Trying to answer?
What is your source
Of information?
What measure will
You use?
What is the
Frequency?
6. Anticipated Resource Needs and Issues (Time and Budget)
7. Communication Plan
Target Audience
Their Issues
Our Message
2
Timing
Messenger / Media
COMMUNICATING
UNANTICIPATED
ADVERSE OUTCOMES
8. Project Plan – How are you going to get there from here?
Action
Responsible Party
Completion Date
Comments
Critical Success Factors To Consider (from other KP initiatives). Which are your top 3-5?
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Get key stakeholders involved – Build Coalitions & Encourage Shared Ownership
Sponsorship – Authorization, participation, celebration
Champion – Don’t leave home without one
Budget Time; Budget Money
Position as a Supplement; Not a Replacement
Align with other organizational priorities and get key stakeholders aligned
Answer the value proposition question – WIIFM (What’s In It For Me)?
Test small before going big
Develop stories and data; share successes and learn from mistakes
Network with your colleagues
Persistence and patience pays off
Other:
Implementation Elements (3-6 month horizon)
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Attend SMT Training
Draft project workplan
Build Leadership’s Awareness & Create Buy-in
Identify Potential Target Areas for early program
implementation and testing
Recruit sponsors, champions, and other team members
Develop partners
Identify resource needs
Procure funding
Define R&R and Develop written policy / procedure as
appropriate
Plan Training and Education program
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Develop measurement strategy
Formalize a communication plan
Schedule physician workshops
Monitor progress and Debrief
incidents
Provide follow-up consultation /
training as necessary
Report learnings and develop
longer-term plan
COMMUNICATING
UNANTICIPATED
ADVERSE OUTCOMES
Some Questions That May Facilitate Your Planning Discussions
 How does our current process of communicating to patients and their families after an unanticipated
adverse outcome work?
 What might be different with the approach we’ve been discussing in this meeting and our current
process?
 What do we need from sponsorship? Who will champion this initiative?
 Who are our key partners and how do we get them involved?
 What will the impact be on staffing, if any, and do key players have the right skills?
 What is our local monitoring strategy going to be?
 How should we prioritize roll-out? What do we need to budget for now?
 How is this initiative connected to other initiatives / programs in our area?
 What do we need from the Program Office?
 What will trigger a report to the SMT and how will the SMT get that information?
 How will we convene the SMT, if necessary? Do we see the team getting together physically?
 What 3 - 5 things do we want all our physicians to know about this initiative?
 How will we train existing physicians and new hires? What about retraining?
 Record other key questions here.
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