Mental Health Event Reporting System: The community feedback period for this idea began on 6/18/2019 and ended on 8/17/2019

What is the problem that needs to be addressed? Please describe how it is related to mental health.
Assessing quality, addressing errors and feeling like consumer concerns are collected is challenging in the current mental health environment. Orange County has a “Grievance Procedure” for clients to express their dissatisfaction with care. The Grievance Procedure is limited to events that clients recognize as possibly harmful/error-prone with the emphasis on addressing an individual. The grievance process is overly formal with little to no emphasis on learning about trends in mental health care. The grievance process doesn’t allow others involved in care to document sentinel events, near misses, or other adverse events. The grievance process doesn’t collect trends for group/team/system learning.

Why is this a concern for Orange County? What can Orange County and other counties learn from this project?
It is unclear what Orange County chooses to be concerned or not concerned about at any given time. What can be learned is if an open-access event reporting system is valuable, respected by users/clients, and able to produce meaningful information products leading to actionable changes.

What is currently being done to resolve this problem in our county and throughout the United States? If applicable: Is it working; why or why not?
In non-mental health settings, many different tools are available for anyone to provide feedback that an error may be occurring. Some examples include: * Rapid Response Teams in the Hospital Setting where anyone, including a patient/patient family member, can call a Rapid Response Team * Food and Drug Administration (FDA) post-marketing surveillance MedWatch Consumer Voluntary Reporting (

What is new or different about this project idea? Please describe how this differs from what is already being done (Question 6). Please list any research that was done on this topic.
Applying an event reporting system to mental health is novel. What is considered a sentinel event for mental health may be different from other specialties. Such events may include: 1) Inappropriate/Unsafe/Incomplete Hospital Discharge 2) Unsafe placements of different types 3) Theft of personal belongings 4) Prescribing Errors 5) Denial of Service 6) Wrong Patient 7) Wrong Site (for ECT and other site-specific procedures) 8) Delirium Inducing events such as loss of eyeglasses, hearing aids, being dressed in ill-fitting clothing, discharge at late night/early morning from any healthcare setting, etc. and many, many others. Reporting for learning is different from reporting a grievance in many ways. Reporting for a grievance is assessing procedural issues, overly formal and is value neutral. As an example, a consumer may report an incident such as theft or physical injury while under the care of another. The grievance procedure provides assurance that laws/processes/procedures were followed correctly. Reporting the same event to an incident reporting repository acknowledges that theft and physical harm are adverse incidents, trends in these adverse incidents are valuable to track and consumers can use this information to make informed healthcare choices. Furthermore, reporting to an incident tracking system is a healthier mindset that emphasizes forgiveness and learning, instead of “gotchas.”

What is the project idea? Please describe how this project will operate.
Create and maintain an incident collection, analysis and reporting system for anyone in the mental health system. Such a system has at least three components: 1) Event submission portal/form to collect the specifics about an event from anyone with a role in the mental health system (i.e. licensed provider, consumer, family member, FSP, activity program, etc). It is hoped that events reported through current, proprietary, closed systems be included in this repository. 2) Back of the House operations to keep the data set as close to reality as possible and possibly follow up on the most serious reports 3) PHI deidentified data reporting and information products available to the general public. This system shall be scalable such that, if successful, it can be rolled out to the other counties in the State of California.

Additional Information:
Respondent skipped this question

June 4, 2019


Innovations Team

Thank you for your submission. The innovation team needs additional information to explore this proposed idea. Please elaborate on your responses as best as possible so that we may work through our review process.

•This idea proposes to create a reporting system in order to track, report and learn from mental health events recorded through this system. What specific areas of learning should be focused on via this system?

This submitter intends such a system to track patient safety events. The grievance procedure is intended to assign blame to persons, which isn’t what causes patient safety events. What causes patient safety events are team based errors.
Many modern organizations consider tracking errors as a required method to improve efficiency and quality (i.e. Six Sigma, Capability Maturity Model, Morbidity and Mortality Conferences, 5 Year Survival Curves, ISO 9001, etc). Tolerating a system with 900,000 estimated errors per year is a choice to make. Start tracking those errors and it is possible to see the trends, learn from the trends and avoid the trends. Based upon the partition of payer (Cal-Optima/Medicaid, Medicare, Medicare Advantage plans like Brand New Day, Private Health Plans, Kaiser Permanente, Employer Health Plans) and the partition of Referral Network (St.Joseph, St. Jude, Hoag, Orange County Global facilities, Royal, etc) you won’t be able to track the trends as-is – each maintains their own separate tracking system, if they decide to track errors at all. Shuffling a patient between payers / referral networks is also a way to hide errors.

Have a conversation with the stakeholders in the Orange County Health System and see what they think about having such a system. Its not what I think should happen, its how stakeholders could use such a system to do better. It is likely that the Safe-Harbors provision from the Informed Consent Project is required for any meaningful outcomes from this particular project submission. If the safe-harbors provisions don’t exist then don’t expect stakeholders to be fond of this project.

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