Report 2016-046 Recommendation 6 Responses

Report 2016-046: Board of Registered Nursing: Significant Delays and Inadequate Oversight of the Complaint Resolution Process Have Allowed Some Nurses Who May Pose a Risk to Patient Safety to Continue Practicing (Release Date: December 2016)

Recommendation #6 To: Registered Nursing, Board of

To ensure that BRN resolves complaints regarding nurses in a timely manner, by March 1, 2017, it should establish a formal, routine process for management to monitor each key stage of the complaint resolution process to determine whether the time frames are being met, the reasons for any delays, and any areas in the process that it can improve.

Annual Follow-Up Agency Response From October 2018

The BRN has established a formal, routine process for management to monitor each key stage of the complaint resolution process to determine whether the time frames are being met, the reasons for any delays, and any areas in the process that it can improve to ensure the BRN resolves complaints regarding nurses in a timely manner.

Completion Date: May 2017

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

The BRN established a formal, routine process for management to monitor each key stage of the complaint resolution process. Specifically, it developed a number of reports that show how long staff are taking to process complaints. In addition, the process that it developed directs managers to use these reports to routinely monitor each key stage of the complaint resolution process to assess whether staff are meeting set time frames, the reasons for delays, and any areas for improvement.

1-Year Agency Response

Completion Date: May 2017
Response Date: June 2018

California State Auditor's Assessment of 1-Year Status: Pending

Although BRN claims it has fully implemented this recommendation, it did not provide evidence demonstrating that it has. Until it does so, we will continue to assess the status of this recommendation as pending.

Auditee did not substantiate its claim of full implementation

6-Month Agency Response

Timeframe/Milestone reports are completed and in full production mode as of March 1, 2017. Reports are delivered on a monthly basis to all enforcement unit managers.

As of April 14, 2017, instructions for managers to use the Timeframe/Milestone reports when evaluating staff workload are included in the Management Monitoring Plans.

In reviewing the reports recommended by the audit the BRN designed additional reports to track Decisions & Appeals, as well as Citation and Fine workloads. These new reports are in final testing stages with the Department of Consumer Affair's (DCA) Office of Information Services. Scheduled implementation of these new reports is anticipated by July 1.

Completion Date: May 2017
Response Date: June 2017

California State Auditor's Assessment of 6-Month Status: Pending

BRN did not provide documentation to substantiate its claim of full implementation.

Auditee did not substantiate its claim of full implementation
Auditee did not address all aspects of the recommendation

60-Day Agency Response

DCA BreEZe BIAs and BRN Subject Matter Experts (SME) worked collectively to develop a series of data reports (i.e. 50 sets) for use in all enforcement units. These reports will allow Managers to identify areas of delays, track team and individual performance, and address process improvements with supervisors and staff.

All reports are in production as of February 1st which will be used by managers to monitor each key stage of the complaint resolution process to ensure time frames are being met, identify reasons for any delays, and potential process improvements.

Each unit has developed a management monitoring plan instructing supervisors in report utilization, timeframe monitoring, and ongoing audits of staff case workload.

Completion Date: February 2017
Response Date: February 2017

California State Auditor's Assessment of 60-Day Status: Partially Implemented

Although BRN developed a number of reports that if used would show how long staff are taking to process complaints, it did not develop policies and procedures that specifically direct managers to, or detail how they should, use these reports to routinely monitor each key stage of the complaint resolution process to assess whether staff are meeting set time frames, the reasons for delays, and any areas for improvement. Until these shortcomings are addressed, we will report this recommendation as partially implemented.

Auditee did not substantiate its claim of full implementation
Auditee did not address all aspects of the recommendation

All Recommendations in 2016-046

Agency responses received are posted verbatim.