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TRANSCRIPT
QUARTERLY REPORT ON ORGANIZATIONAL PERFORMANCE EXCELLENCE
FIRST STATE FISCAL QUARTER 2017July, August, September 2016
Sharon L. Sprague Superintendent
November 18, 2016
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Table of Contents
Introduction.............................................................................................................................1
Comparative Statistics..............................................................................................................4
Joint Commission Performance MeasuresHospital Based Inpatient Psychiatric Services (ORYX Measures)............................................15
Admissions Screening.................................................................................................17Physical Restraint.......................................................................................................18Seclusion.................................................................................................................... 19Multiple Antipsychotic Medications...........................................................................20Justification of Multiple Antipsychotic Medications...................................................22
Joint Commission Priority Focus AreasContracts Management..............................................................................................24Medication Management...........................................................................................26Consumer Surveys......................................................................................................29Fall Reduction Strategies............................................................................................38Pain Assessment.........................................................................................................42
Strategic Performance ExcellenceProcess Improvement Plans...................................................................................................47
Dietary........................................................................................................................50Facilities......................................................................................................................51Health Information Management..............................................................................52Human Resources...................................................................................................... 54Infection Control........................................................................................................60Medical Staff.............................................................................................................. 65Nursing.......................................................................................................................71Outpatient Services/Forensics...................................................................................79Pharmacy Services......................................................................................................84Social Services............................................................................................................97Staff Education and Development............................................................................100Therapeutic Services................................................................................................103
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Introduction
This edition of the Dorothea Dix Psychiatric Center Quarterly Report on Organizational Performance Excellence is designed to address overall organizational performance in a systems improvement approach instead of a purely compliance approach. The structure of the report also reflects a shift to this focus on meaningful measures of organizational process improvement, while maintaining measures of compliance that are mandated though regulatory and legal standards.
This change was inspired, in part by the work done for both Riverview and Dorothea Dix Psychiatric Centers by Courtemanche and Associates, during a Joint Commission Mock Survey in February 2012. During this visit, the consultants identified a gap in the methods used to evaluate and improve organizational performance. It was recommended that the methodology used for organizational performance improvement be transitioned from a process that relied completely on meeting regulatory standards, collection, and reporting on information as a matter of routine, to a more focused approach that sought out areas for improvement that were clearly identified as performance priorities. In addition, a review of current practices in quality management represented by the work of groups such as the American Society for Quality, National Quality Forum, Baldrige National Quality Program and the National Patient Safety Foundation, all recommend a systems-based approach where organizational improvement activities are focused on strategic priorities rather than compliance standards.
There are three major sections that make up this modified report:
The first section reflects traditional measures related to Comparative Statistics.
The second section describes the hospital’s performance with regard to Joint Commission performance measures that are derived from the Hospital Based Inpatient Psychiatric Services (HBIPS) that are reflected in the Joint Commissions quarterly ORYX Report and priority focus areas that are referenced in the Joint Commission standards:
I. Data Collection (PI.01.01.01)II. Data Analysis (PI.02.01.01, PI.02.01.03)III. Performance Improvement (PI.03.01.01)
The third section encompasses those departmental process improvement projects that are designed to improve the overall effectiveness and efficiency of the hospital’s operations and contribute to the system’s overall strategic performance excellence.
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As with any change in how organizations operate, there are early adopters and those whose adoption of system changes is delayed. It is anticipated that over the next year, further contributors to this section of strategic performance excellence will be added as opportunities for improvement and methods of improving operational functions are defined.
Respectfully Submitted,
Joseph RiddickJoseph RiddickDirector of Integrated Quality and Informatics
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The comparative statistics reports include the following elements:
Patient Injury Rate
Elopement Rate
30 Day Readmit Rate
Percent of Patients Restrained
Hours of Restraint
Percent of Patients Secluded
Hours of Seclusion
Confinement Event Breakdown
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Number of patient injury incidents that occurred for every 1000 inpatient days. For example, a rate of 0.5 means that 1 injury occurred for each 2000 inpatient days. The NRI standards for measuring patient injuries differentiate between injuries that are considered reportable to the Joint Commission as a performance measure and those injuries that are of a less severe nature. While all injuries are currently reported internally, only certain types of injuries are documented and reported to NRI for inclusion in the performance measure analysis process. This comparative statistic graph only includes those events that are considered “Reportable” by NRI.
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COMPARATIVE STATISTICS
“Reportable” injuries include those that require: Medical Intervention Hospitalization Death Occurred
“Non-reportable” injuries include those that require: No Treatment Minor First Aid
Injury Severity:
No Treatment – The injury received by a patient may be examined by a clinician but no treatment is applied to the injury.
Minor First Aid – The injury received is of minor severity and requires the administration of minor first aid.
Medical Intervention Needed – The injury received is severe enough to require the treatment of the patient by a licensed practitioner, but does not require hospitalization.
Hospitalization Required – The injury is so severe that it requires medical intervention and treatment as well as care of the injured patient at a general acute care medical ward within the facility or at a general acute care hospital outside the facility.
Death Occurred – The injury received was so severe that it resulted in, or complications of the injury lead to, the termination of the life of the injured patient.
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COMPARATIVE STATISTICS
Type and Cause of Injury by Month
Type - Cause July August September 1Q2017Accident 1 6 3 10FallOther 1 1Patient to Patient Incident 3 3Self-Injurious Behavior 1 1Total 1 11 3 15
Severity of Injury by Month
Severity July August September 1Q2017No Treatment 1 6 7Minor First Aid 5 2 7Medical Intervention Required 1 1Hospitalization RequiredDeath OccurredTotal 1 11 3 15
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COMPARATIVE STATISTICS
Number of elopement incidents that occurred for every 1000 inpatient days. For example, a rate of 0.25 means that 1 elopement occurred for each 4000 inpatient days.
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COMPARATIVE STATISTICS
Percent of discharges from the facility that returned within 30 days of a discharge of the same patient from the same facility. For example, a rate of 10.0 means that 10% of all discharges were readmitted within 30 days.
Readmissions may be attributable to several factors including court ordered returns related to non-compliance with PTP parameters. The information contained in this graph does not differentiate between those returns that are court ordered and those that may be attributable to other factors related to patient care.
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COMPARATIVE STATISTICS
Percent of unique patients who were restrained at least once. The NRI and Joint Commission standards require that all types of restraint, including manual holds of less than 5 minutes be included in this indicator. For example, rates of 4.0 means that 4% of the unique patients served were restrained at least once, for any amount of time.
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COMPARATIVE STATISTICS
Number of hours patients spent in restraint for every 1000 inpatient hours. For example, a rate of 1.6 means that 2 hours were spent in restraint for each 1250 inpatient hours.
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COMPARATIVE STATISTICS
Percent of unique patients who were secluded at least once. For example, a rate of 3.0 means that 3% of the unique patients served were secluded at least once.
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COMPARATIVE STATISTICS
Number of hours patients spent in seclusion for every 1000 inpatient hours. For example, a rate of 0.8 means that 1 hour was spent in seclusion for each 1250 inpatient hours.
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COMPARATIVE STATISTICS
Confinement Event Breakdown
Manual Hold
Mechanical Restraint
Locked Seclusio
n
Grand Total
% of Total Cumulative %
MD1305 18 5 23 44.23% 44.23%MD1889 6 2 8 15.38% 59.61%MD487 4 2 6 11.54% 71.15%MD2028 2 2 4 7.69% 78.85%MD2087 2 2 4 7.69% 86.54%MD24 2 2 3.85% 90.38%MD2086 2 2 3.85% 94.23%MD2092 1 1 1.92% 96.15%MD2016 1 1 1.92% 98.08%MD1157 1 1 1.92% 100.00%
39 0 13 52
Unit Manual Hold Locked Seclusion Event Jul Aug SepChamberlain 21 5 Manual Hold 11 14 14Hamlin 8 2 Locked Seclusion 4 3 6Knox 10 6
Note: Graph includes Manual Holds, Mechanical Restraints, Locked and Open Door Seclusions
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COMPARATIVE STATISTICS
Hospital Based Inpatient Psychiatric Services (ORYX Data Elements)
The Joint Commission Quality Initiatives
In 1987, The Joint Commission announced its Agenda for Change, which outlined a series of major steps designed to modernize the accreditation process. A key component of the Agenda for Change was the eventual introduction of standardized core performance measures into the accreditation process. As the vision to integrate performance measurement into accreditation became more focused, the name ORYX® was chosen for the entire initiative. The ORYX initiative became operational in March of 1999, when performance measurement systems began transmitting data to The Joint Commission on behalf of accredited hospitals and long term care organizations. Since that time, home care and behavioral healthcare organizations have been included in the ORYX initiative.
The initial phase of the ORYX initiative provided healthcare organizations a great degree of flexibility, offering greater than 100 measurement systems capable of meeting an accredited organization’s internal measurement goals and the Joint Commission’s ORYX requirements. This flexibility, however, also presented certain challenges. The most significant challenge was the lack of standardization of measure specifications across systems. Although many ORYX measures appeared to be similar, valid comparisons could only be made between healthcare organizations using the same measures that were designed and collected based on standard specifications. The availability of over 8,000 disparate ORYX measures also limited the size of some comparison groups and hindered statistically valid data analyses. To address these challenges, standardized sets of valid, reliable, and evidence-based quality measures have been implemented by The Joint Commission for use within the ORYX initiative.
Hospital Based Inpatient Psychiatric Services (HBIPS) Core Measure Set
Driven by an overwhelming request from the field, The Joint Commission was approached in late 2003 by the National Association of Psychiatric Health Systems (NAPHS), the National Association of State Mental Health Program Directors (NASMHPD) and the NASMHPD Research Institute, Inc. (NRI) to work together to identify and implement a set of core performance measures for hospital based inpatient psychiatric services. Project activities were launched in March 2004. At this time, a diverse panel of stakeholders convened to discuss and recommend an overarching initial framework for the identification of HBIPS core performance measures. The Technical Advisory Panel (TAP) was established in March 2005 consisting of many prominent experts in the field.
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JOINT COMMISSION
The first meeting of the TAP was held May 2005 and a framework and priorities for performance measures was established for an initial set of core measures. The framework consisted of seven domains:
Assessment Treatment Planning and Implementation Hope and Empowerment Patient Driven Care Patient Safety Continuity and Transition of Care Outcomes
The current HIBIPS standards reflected in this report are designed to reflect these core domains in the delivery of psychiatric care.
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JOINT COMMISSION
Admissions Screening (HBIPS 1)For Violence Risk, Substance Use, Psychological Trauma History, and Patient Strengths
Description: Patients admitted to a hospital based, inpatient psychiatric setting who are screened within the first three days of admission for all of the following: risk of violence to self or others, substance use, psychological trauma history and patient strengths.
Rationale: Substantial evidence exists that there is a high prevalence of co-occurring substance use disorders as well as history of trauma among persons admitted to acute psychiatric settings. Professional literature suggests that these factors are under-identified yet integral to current psychiatric status and should be assessed in order to develop appropriate treatment (Ziedonis, 2004; NASMHPD, 2005). Similarly, persons admitted to inpatient settings require a careful assessment of risk for violence and the use of seclusion and restraint. Careful assessment of risk is critical to safety and treatment. Effective, individualized treatment relies on assessments that explicitly recognize patients’ strengths. These strengths may be characteristics of the individuals themselves, supports provided by families and others, or contributions made by the individuals’ community or cultural environment (Rapp, 1998). In the same way, inpatient environments require assessment for factors that lead to conflict or less than optimal outcomes.
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JOINT COMMISSION
Physical Restraint (HBIPS 2)Hours of Use
Description: The total number of hours that all patients admitted to a hospital-based, inpatient psychiatric setting were maintained in physical restraint.
Rationale: Mental health providers that value and respect an individual’s autonomy, independence and safety seek to avoid the use of dangerous or restrictive interventions at all times (Donat, 2003). The use of seclusion and restraint is limited to situations deemed to meet the threshold of imminent danger and when restraint and seclusion are used; such use is rigorously monitored and analyzed to prevent future use. Providers also seek to prevent violence or aggression from occurring in their treatment environments by focusing their attention on prevention activities that have a growing evidence base (Donat, 2003).
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JOINT COMMISSION
Seclusion (HBIPS 3) Hours of Use
Description: The total number of hours that all patients admitted to a hospital based inpatient psychiatric setting were held in seclusion.
Rationale: Mental health providers that value and respect an individual’s autonomy, independence and safety seek to avoid the use of dangerous or restrictive interventions at all times (Donat, 2003). The use of seclusion and restraint is limited to situations deemed to meet the threshold of imminent danger and when restraint or seclusion are used; such use is rigorously monitored and analyzed to prevent future use. Providers also seek to prevent violence or aggression from occurring in their treatment environments by focusing their attention on prevention activities that have a growing evidence base (Donat, 2003).
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JOINT COMMISSION
Multiple Antipsychotic Medications on Discharge (HBIPS 4)
Description: Patients discharged from a hospital based inpatient psychiatric setting on two or more antipsychotic medications.
Rationale: Research studies have found that 4-35% of outpatients and 30-50% of inpatients treated with an antipsychotic medication concurrently received 2 or more antipsychotics (Covell, Jackson, Evans, & Essock, 2002; Ganguly, Kotzan, Miller, Kennedy, & Martin, 2004; Gilmer, Dolder, Folsom, Mastin, & Jeste, 2007; Kreyenbuhl, Valenstein, McCarthy, Ganocyz, & Blow, 2006; Stahl & Grady, 2004). One study reported 4.6% of patients concurrently received 3 or more antipsychotics (Jaffe & Levine, 2003). These findings are seen across diverse sectors: state mental health authorities, the Veterans Health System and Medicaid-financed care. Antipsychotic polypharmacy can lead to greater side effects, often without improving clinical outcomes (Ananth, Parameswaran, & Gunatilake, 2004; Stahl & Grady, 2004). As a result, a range of stakeholders have called for efforts to reduce unnecessary use of multiple antipsychotics (Centorrino, Gören, Hennen, Salvatore, Kelleher, & Baldessarini, 2004; Gilmer, Dolder, Folsom, Mastin, & Jeste, 2007; National Association of State Mental Health Program Directors, 2001; University HealthSystem Consortium, 2006). Practice guidelines recommend the use of a second antipsychotic only after multiple trials of a single antipsychotic have proven inadequate (American Psychiatric Association [APA] Practice Guidelines, 2004). Randomized controlled trials (RCTs) provide some evidence to support augmentation with a second antipsychotic in treatment resistant patients. Most of these studies were limited to augmentation of clozapine with another second-generation antipsychotic (Tranulis, Skalli, Lalonde, & Nicole, 2008). Among patients without a documented history of previous treatment failures of antipsychotic monotherapy, multiple RCTs and other controlled trials failed to show a benefit of antipsychotic polypharmacy over monotherapy (Ananth, Parameswaran, & Gunatilake, 2004; Centorrino, Gören, Hennen, Salvatore, Kelleher, & Baldessarini, 2004; Potkin, Thyrum, Alva, Bera, Yeh, & Arvanitis, 2002; Shim et al., 2007; Stahl,& Grady, 2004). Clinical circumstances, such as shorter inpatient stays, may require hospitals to discharge a patient on multiple antipsychotics with an aftercare plan to transition to monotherapy. In such cases, effective communication between the inpatient and aftercare clinician is an essential element of care.
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JOINT COMMISSION
Multiple Antipsychotic Medications on Discharge (HBIPS 4)
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JOINT COMMISSION
Multiple Antipsychotic Medications at Discharge with Justification (HBIPS 5)
Description: Patients discharged from a hospital based inpatient psychiatric setting on two or more antipsychotic medications with appropriate justification.
Rationale: Research studies have found that 4-35% of outpatients and 30-50% of inpatients treated with an antipsychotic medication concurrently received 2 or more antipsychotics (Covell, Jackson, Evans, & Essock, 2002; Ganguly, Kotzan, Miller, Kennedy, & Martin, 2004; Gilmer, Dolder, Folsom, Mastin, & Jeste, 2007; Kreyenbuhl, Valenstein, McCarthy, Ganocyz, & Blow, 2006; Stahl & Grady, 2004). One study reported 4.6% of patients concurrently received 3 or more antipsychotics (Jaffe & Levine, 2003). These findings are seen across diverse sectors: state mental health authorities, the Veterans Health System and Medicaid-financed care. Antipsychotic polypharmacy can lead to greater side effects, often without improving clinical outcomes (Ananth, Parameswaran, & Gunatilake, 2004; Stahl & Grady, 2004). As a result, a range of stakeholders have called for efforts to reduce unnecessary use of multiple antipsychotics (Centorrino, Gören, Hennen, Salvatore, Kelleher, & Baldessarini, 2004; Gilmer, Dolder, Folsom, Mastin, & Jeste, 2007; National Association of State Mental Health Program Directors, 2001; University HealthSystem Consortium, 2006).
Practice guidelines recommend the use of a second antipsychotic only after multiple trials of a single antipsychotic have proven inadequate (American Psychiatric Association [APA] Practice Guidelines, 2004). Randomized controlled trials (RCTs) provide some evidence to support augmentation with a second antipsychotic in treatment resistant patients. Most of these studies were limited to augmentation of clozapine with another second-generation antipsychotic (Tranulis, Skalli, Lalonde, & Nicole, 2008). Among patients without a documented history of previous treatment failures of antipsychotic monotherapy, multiple RCTs and other controlled trials failed to show a benefit of antipsychotic polypharmacy over monotherapy (Ananth, Parameswaran, & Gunatilake, 2004; Centorrino, Gören, Hennen, Salvatore, Kelleher, & Baldessarini, 2004; Potkin, Thyrum, Alva, Bera, Yeh, & Arvanitis, 2002; Shim et al., 2007; Stahl,& Grady, 2004). Clinical circumstances, such as shorter inpatient stays, may require hospitals to discharge a patient on multiple antipsychotics with an aftercare plan to transition to monotherapy. In such cases, effective communication between the inpatient and aftercare clinician is an essential element of care.
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JOINT COMMISSION
Multiple Antipsychotic Medications at Discharge with Justification (HBIPS 5)
Note: If there is no result for a particular month, it means no patients were discharged on multiple antipsychotics during that month
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JOINT COMMISSION
Contracts Management
TJC LD.04.03.09 The same level of care should be delivered to patients regardless of whether services are provided directly by the hospital or through contractual agreement. Leaders provide oversight to make sure that care, treatment, and services provided directly are safe and effective. Likewise, leaders must also oversee contracted services to make sure that they are provided safely and effectively.
1Q2017 ResultsContractor Program Administrator Summary of PerformanceAffiliated Laboratory Carolyn Dimek
Director of NursingAll indicators exceeded standards.
AMES Maine Mark FaulknerActing Director of Facilities
All indicators exceeded standards.
Casella Waste Systems Mark FaulknerActing Director of Facilities
All indicators met standards.
CES, Inc. Mark FaulknerActing Director of Facilities
All indicators met or exceeded standards.
Comprehensive Pharmacy Services
Carolyn DimekDirector of Nursing
All indicators met or exceeded standards.
Harriman Associates Mark FaulknerActing Director of Facilities
All indicators met or exceeded standards.
Jackson & Coker Dr. Michelle GardnerClinical Director
Contract not utilized during timeframe.
Liberty Healthcare Physicians and/or Mid-Levels On Call
Dr. Michelle GardnerClinical Director
All indicators met standards.
Liberty Healthcare Psychiatric Nurse Practitioner
Dr. Michelle GardnerClinical Director
All indicators met standards.
Locum Tenens Psychiatry Dr. Michelle GardnerClinical Director
Contract not utilized during timeframe.
MD-IT Transcription Michelle WelchMedical Records Administrator
All indicators met standards.
Northeast Cardiology Associates (NECA)
Dr. Michelle GardnerClinical Director
All indicators met standards.
Norris, Inc. Mark FaulknerActing Director of Facilities
All indicators met standards.
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JOINT COMMISSION
Otis Elevator Mark FaulknerActing Director of Facilities
All indicators met standards.
Penobscot Community Health Care (PCHC)
Dr. Michelle GardnerClinical Director
Indicator met standards.
Project Staffing Carol DavisBusiness Manager
All indicators met or exceeded standards.
Securitas Mark FaulknerActing Director of Facilities
All indicators met or exceeded standards.
The Healing Staff Dr. Michelle GardnerClinical Director
Contract not utilized during timeframe.
UniFirst Mark FaulknerActing Director of Facilities
All indicators met standards.
Vista Staffing Dr. Michelle GardnerClinical Director
Contract not utilized during timeframe.
WBRC Architects Engineers Mark FaulknerActing Director of Facilities
All indicators met standards.
Worldwide Travel Staffing Carolyn DimekDirector of Nursing
All indicators met standards.
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JOINT COMMISSION
Medication ManagementMedication Errors and Adverse Reactions
TJC PI.01.01.01 EP14: The hospital collects data on the following: Significant medication errors. (See also LD.04.04.01, EP 2; MM.08.01.01, EP 1)
TJC PI.01.01.01 EP15: The hospital collects data on the following: Significant adverse drug reactions. (See also LD.04.04.01, EP 2; MM.08.01.01, EP 1)
Number of medication error events that occurred for every 100 episodes of care (duplicated patient count). For example, a rate of 1.6 means that 2 medication error events occurred for each 125 episodes of care.
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JOINT COMMISSION
Medication errors are classified according to four major areas related to the area of service delivery. The error must have resulted in some form of variance in the desired treatment or outcome of care. A variance in treatment may involve one incident but multiple medications; each medication variance is counted separately irrespective of whether it involves one error event or many. Medication error classifications include:
Prescribing : An error of prescribing occurs when there is an incorrect selection of drug, drug dose, dosage form, quantity, route, concentration, rate of administration, or instructions for use of a drug product ordered or authorized by physician or other legitimate prescriber. Errors may occur due to improper evaluation of indications, contraindications, known allergies, existing drug therapy and other factors. Illegible prescriptions or medication orders that lead to patient level errors are also defined as errors of prescribing in identifying and ordering the appropriate medication to be used in the care of the patient.
Dispensing: An error of dispensing occurs when the incorrect drug, drug dose or concentration, dosage form, or quantity is formulated and delivered for use to the point of intended use.
Administration : An error of administration occurs when there is an incorrect selection and administration of drug, drug dose, dosage form, quantity, route, concentration, rate of administration, or instructions for use of a drug product ordered or authorized by physician or other legitimate prescriber.
Complex : An error which resulted from two or more distinct errors of different types is classified as a complex error.
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JOINT COMMISSION
Medication Dispensing Process Michael Migliore, RPh
Measure Unit Baseline 4Q2016 Goal 1Q2017 2Q201
7 3Q2017 4Q2017
Controlled Substance Loss Data:Daily Pyxis-CII Safe Compare Report. All 0% Target:
Actual:0%0%
0% 0% 0%
Monthly CII Safe Vendor Receipt Report. Rx 0 Target:
Actual:00
0 0 0
Monthly Pyxis Unresolved Controlled Drug Discrepancies.
All 0/month
Target:Actual:
00
0 0 0
Medication Management Monitoring:Measures of drug reactions, adverse drug events and other management data.
Rx 2 Target:Actual:
00
0 0 0
Resource Documentation Reports of Clinical Interventions.
Rx 397 Actual: 867
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JOINT COMMISSION
Consumer Surveys
TJC PI.01.01.01 EP16: The hospital collects data on the following: Patient perception of the safety and quality of care, treatment, and services.
In order to gain a perspective on the quality of care provided to our patients from the patient’s perspective, Dorothea Dix Psychiatric Center conducts two patient surveys; the Care Transition Measures Survey and the Inpatient Customer Survey.
Care Transition Measures Survey
The Care Transition Measures Survey (CTM-3) is a three question survey that is designed to ascertain the degree of patient understanding of and satisfaction with the discharge planning and preparation process. Dorothea Dix conducts a telephone poll of discharged patients approximate one to two weeks after discharge. This provides an opportunity to make a connection with the patients as they transition into the community setting and, on occasion, has provided the discharged patient with a support mechanism or safety net on those few occasions when they are having difficulties with the discharge transition and are potentially de-stabilizing.
The Care Transition Measure Survey questions are as follows:1. The hospital staff took my preference and those of my family or caregiver into account
in deciding what my health care needs would be when I left the hospital.2. When I left the hospital, I had a good understanding of the things I was responsible for
in managing my health.3. When I left the hospital, I clearly understood the purpose for taking each of my
medications.
All questions are answered on a four part Likert scale; 1) strongly disagree, 2) disagree, 3) agree, and 4) strongly agree. Patients that answer “I don’t’ know” or “I don’t remember” are designated with a “99” score and are considered neutral responses and are not included in the results calculations.
CTM-3 Survey Response Rate:
July August September 1Q2017
Number of Patients Discharged 12 11 9 32Number of Survey Responses 4 1 1 6
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JOINT COMMISSION
Survey Response Rate 33% 9% 11% 19%CTM-3 Percent of Positive (agree or strongly agree):
July August September 1Q2017The hospital staff took my preference and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital.
75%3/4
100%1/1
100%1/1
83%5/6
When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
100%4/4
100%1/1
100%1/1
100%6/6
When I left the hospital, I clearly understood the purpose for taking each of my medications.
100%4/4
100%1/1
100%1/1
100%6/6
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JOINT COMMISSION
Inpatient Consumer Survey
The Inpatient Customer Survey (ICS) is a standardized national survey of customer satisfaction. The National Association of State Mental Health Program Directors Research Institute (NRI) collects data from state psychiatric hospitals throughout the country in an effort to compare the results of patient satisfaction in six areas or domains of focus. These domains include Outcomes, Dignity, Rights, Participation, Environment, and Empowerment.
NRI Inpatient Consumer Survey (ICS) Response Rate:
July August September 1Q2017Number of patients discharged 12 11 9 32Number of survey responses 7 2 2 11Survey response rate 58% 18% 22% 34%
Surveys are distributed to all patients prior to discharge and when returned are tabulated in a database created for the purpose of collecting and uploading the data elements to NRI. On a monthly basis, the data is uploaded to NRI and aggregated with the results of the Riverview Psychiatric Center and other state psychiatric hospitals throughout the country. Reports on the percent of positive responses are returned along with aggregated comparative data from participating hospitals.
Data on the return rate of the survey administered to Dorothea Dix patients and the results of the comparative analysis follows. When the results are blank for a month on the following graphs, it means that no surveys were completed during that month.
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JOINT COMMISSION
Outcome Domain
1. I am better able to deal with crisis.2. My symptoms are not bothering me as much.3. I do better in social situations.4. I deal more effectively with daily problems.
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Dignity Domain
1. I was treated with dignity and respect.2. Staff here believed that I could grow, change and recover.3. I felt comfortable asking questions about my treatment and medications.4. I was encouraged to use self-help/support groups.
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JOINT COMMISSION
Rights Domain
1. I felt free to complain without fear of retaliation.2. I felt safe to refuse medication or treatment during my hospital stay.3. My complaints and grievances were addressed.
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JOINT COMMISSION
Participation Domain
1. I participated in planning my discharge.2. Both I and my doctor, or therapist from the community, were actively involved in my
hospital treatment plan.3. I had an opportunity to talk with my doctor or therapist from the community prior to
discharge.
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JOINT COMMISSION
Environment Domain
1. The surroundings and atmosphere at the hospital helped me get better.2. I felt I had enough privacy in the hospital.3. I felt safe while I was in the hospital.4. The hospital environment was clean and comfortable.
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JOINT COMMISSION
Empowerment Domain
1. I had a choice of treatment options.2. My contact with my doctor was helpful.3. My contact with nurses and therapists was helpful.
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JOINT COMMISSION
Fall Reduction Strategies
TJC PI.01.01. EP38 The hospital evaluates the effectiveness of all fall reduction activities including assessment, interventions and education.
Dorothea Dix Psychiatric Center has had a Falls Risk Management Team in existence for several years. The role of this team is to conduct root cause analyses on each of the falls incidents and to identify trends and common contributing factors and to make recommendations for changes in the environment and process of care for those patients identified as having a high potential for falls.
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JOINT COMMISSION
Fall Reduction Nursing Interventions Janet Babcock, RN
I. Measure Name: Patient Falls - Establishing a Culture of SafetyMeasure Description: Up to 50% of hospitalized patients are at risk for falls, and almost half of those who fall suffer an injury (American Nurse Today, Special Supplement to American Nurse Today - Best Practices for Falls Reduction: A Practical Guide. Multiple authors, March 2011, 6. No 2). The objective of Nursing’s Fall Performance Improvement measure is to ensure compliance with Nursing Procedure F-10 with the overall objective of ensuring that information is gathered about each patient for problem identification in order to ensure health and safety needs are met.Type of Measure: Performance Improvement
All patient falls in
1Q2017
Falls risk assessment completed
Falls Progress Note 565
completed and in patient’s medical
record
Falls risk score of 6 or higher: problem 6.1
initiated(164 A & B)
Falls riskscore
documented on kardex and in front of chart
20(Including 2 that did not meet definition)
Yes: 13No: 6N/A: 1
Yes: 18No: 2
Yes: 18No: 0N/A: 2
Yes: 16No: 2N/A: 2
Overall Compliance 68% 90% 100% 89% 87%
Data Analysis: There were 20 falls in the 1st quarter: 5 in July with one not meeting definition, 9 in August with 1 not meeting definition, and 6 in September with all meeting the definition. Many of the falls this quarter are same-patient falls attributed to patients who had repeated falls over lengthy admissions. Overall compliance for the 1st quarter is 87%. This is an increase of 4% over 4th quarter FY2016.
Action Plan: Auditing, the Nurse Supervisor provides education to staff during auditing process. Nursing administration will continue to follow up and audit all falls.
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Pain Assessment
Elements of Performance for Joint Commission Standard PC.01.02.07
1. The hospital conducts a comprehensive pain assessment that is consistent with its scope of care, treatment, and services and the patient’s condition. (See also PC.01.02.01, EP 2; RI.01.01.01, EP 8)2. The hospital uses methods to assess pain that are consistent with the patient’s age, condition, and ability to understand.3. The hospital reassesses and responds to the patient’s pain, based on its reassessment criteria.4. The hospital either treats the patient’s pain or refers the patient for treatment. Source: The Joint Commission: The Source. The fifth “vital sign” complying with pain management standard PC. 01.02.07. November 2011, Vol 9. Issue 11.
Pain Re-Assessment Audit Form Janet Babcock, RN
Pain Assessment (Patient Recovery)Pain is common. About 9 in 10 Americans regularly suffer from pain, and pain is the most common reason individuals seek health care. Each year, an estimated 25 million Americans experience acute pain due to injury or surgery and another 50 million suffer chronic pain (Berry. P., Chapman. C., Covington. E., Dahl. J., Katz. J., Miaskowski. C., Mc Lean. M., 2001. Pain: Current understanding of assessment, Management, and treatment).
Pain is often undertreated, with recent studies, reports, and a position statement suggesting that many types of pain (e.g., postoperative pain, cancer pain, chronic non-cancer pain) and patient populations (e.g., elderly patients, children, minorities, substance abusers) are undertreated. Data from a 1999 survey suggest that only 1 in 4 individuals with pain receive appropriate therapy (Berry. P., Chapman. C., Covington. E., Dahl. J., Katz. J., Miaskowski. C., Mc Lean. M., 2001. Pain: Current understanding of assessment, Management, and treatment).
Untreated pain impairs an individual’s ability to carry out their activities of daily living diminishing their quality of life; it can cause anxiety, fear, anger, or depression. Nursing acknowledges the impact of untreated pain on patient recovery and for this reason the objective of Nursing’s Pain PI is to ensure patients are being assessed for pain and re-assessed if required.
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JOINT COMMISSION
I. Measure Name: Pain Reassessment Audit - Patient RecoveryMeasure Description: Untreated pain impairs an individual’s ability to carry out their activities of daily living diminishing his or her quality of life; it can cause anxiety, fear, anger, or depression. Nursing acknowledges the impact of untreated pain on patient recovery and for this reason the objective of Nursing’s Pain PI is to ensure patients are being assessed for pain and re-assessed if required. Type of Measure: Performance Improvement
Results
Target Data elementsBaselineJan/Feb
2013
1Q2017
2Q201
7
3Q201
7
4Q 2017 YTD
100% Compliance
Number of audits performed 89 116 116
Number of patients with pain reported on Form 838
29 65 65
Number of reassessments completed
11 47 47
Number of reassessments reported within clinically appropriate timeframe(1-2 hours after oral medication and within 1 hour of intramuscular injection)
11 47 47
Compliance with reassessment 38% 72% 72%
Compliance with reassessment timeframe
38% 72% 72%
Data Analysis: All MARs are reviewed for the month for pain reported and corresponding reassessment; the information is located on form #838 ‘Pain Flow Sheet’. The information is documented on the ‘Pain Assessment and Re-assessment Audit Form’ for monthly, quarterly, and yearly calculation. Audits were initiated in January 2013. January and February 2013 comprise the baseline data of 38%. 1st Quarter of FY 2017 showed a 5% decrease, from 77% in Q42016, to 72% in 1Q2017. This is a 34% increase from baseline.
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JOINT COMMISSION
Action Plan: Nursing remains below the goal of 90% compliance. Nursing Administration continues to address this issue and will reinforce with the Clinical Nurse Managers to ensure that Pain Re-Assessments are being completed for each documented report of pain and within the clinically appropriate timeframe. Clinical Nurse Managers will address documentation compliance with staff members who are not completing these assessments.
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JOINT COMMISSION
II. Measure Name: Pain Audit Shift Assessment - Patient RecoveryMeasure Description: Untreated pain impairs an individual’s ability to carry out their activities of daily living diminishing his or her quality of life; it can cause anxiety, fear, anger, or depression. Nursing acknowledges the impact of untreated pain on patient recovery and for this reason the objective of Nursing’s Pain PI is to ensure patients are being assessed for pain and re-assessed if required. Type of Measure: Performance Improvement
Results
Target Data elementsBaselineJan/Feb
2013
1Q201
7
2Q201
7
3Q201
7
4Q 201
7YTD
100% Compliance
Number of audits completed 36 106 106
Number of audits having 2 shift assessments completed that assesses for the presence and intensity of pain within 24 hours
12 61 61
Overall Compliance 33% 58% 58%
Data Analysis: All Medication Administration Records (MARs) for each unit will be audited for a 24 hour period. Form #841 ‘Daily Shift Assessment for the Presence of Pain’ is used at least once every 12 hours to assess each patient for the presence and intensity of pain. The form is audited to ensure there are 2 pain assessments completed each 24 hour period. Audits were initiated in January 2013. January and February 2013 comprise the baseline data of 33%. 1st
quarter 2017 showed a decrease of 14% from 72% in 4 th quarter FY2016, to 58% this quarter; however, that is an increase of 25% over baseline data.
The recent increases in compliance from established baseline may be partially attributed to the addition of a checkbox on each patient’s MAR for nursing reminder to complete the pain assessment documentation. This was instituted January 1, 2016 by a joint decision of Nursing Administration and Pharmacy to increase compliance with documentation requirements.
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JOINT COMMISSION
Action Plan: Nursing remains below the goal of 90% compliance. Nursing Administration continues to address this issue and will reinforce with the Clinical Nurse Managers to ensure that pain is being assessed at least every 12 hours for every patient. Clinical Nurse Managers will address documentation compliance with staff members who are not completing these assessments.
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STRATEGIC PERFORMANCE EXCELLENCE
Process Improvement PlansPriority Focus Areas for Strategic Performance Excellence
In an effort to ensure that quality management methods used within the Maine Psychiatric Hospitals System are consistent with modern approaches of systems engineering, culture transformation, and process focused improvement strategies and in response to the evolution of Joint Commission methods to a more modern systems-based approach instead of compliance-based approach
Building a framework for patient recovery by ensuring fiscal accountability and a culture of organizational safety through the promotion of…
The conviction that staff members are concerned with doing the right thing in support of patient rights and recovery;
A philosophy that promotes an understanding that errors most often occur as a result of deficiencies in system design or deployment;
Systems and processes that strive to evaluate and mitigate risks and identify the root cause of operational deficits or deficiencies without erroneously assigning blame to system stakeholders;
The practice of engaging staff members and patients in the planning and implementing of organizational policy and protocol as a critical step in the development of a system that fulfills ethical and regulatory requirements while maintaining a practicable workflow;
A cycle of improvement that aligns organizational performance objectives with key success factors determined by stakeholder defined strategic imperatives;
Enhanced communications and collaborative relationships within and between cross-functional work teams to support organizational change and effective process
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STRATEGIC PERFORMANCE EXCELLENCE
improvement; Transitions of care practices where knowledge is freely shared to improve the safety of patients before, during, and after care;
A just culture that supports the emotional and physical needs of staff members, patients, and family members that are impacted by serious, acute, and cumulative events.
Strategic Performance Excellence Model Reporting Process
Department of Health and Human Services Goals
Protect and enhance the health and well-being of Maine people.Promote independence and self-sufficiency.
Protect and care for those who are unable to care for themselves.Provide effective stewardship for the resources entrusted to the Department.
Dorothea Dix and Riverview Psychiatric CentersPriority Focus Areas
Ensure and Promote Fiscal Accountability by…Identifying and employing efficiency in operations and clinical practice.
Promoting vigilance and accountability in fiscal decision-making.
Promote a Safety Culture by…Improving communication.
Improving staffing capacity and capability.Evaluating and mitigating errors and risk factors.
Promoting critical thinking.Supporting the engagement and empowerment of staff members.
Enhance Patient Recovery by…Develop active treatment programs and options for patients.
Supporting patients in their discovery of personal coping and improvement activities.
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STRATEGIC PERFORMANCE EXCELLENCE
Each department determines unique opportunities and methods to address the hospital goals.
The Quarterly Report consists of the following:
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DEFINE
Opportunities for Improvement (OFIs)
MEASURE
IMPROVE
Current Work Flow Process
Identify RootCauses ofPerformance Gaps
ANALYZE
CONTROL
Current Performance Gaps
Work Process Plans and Procedures
Implement the Planned Changes
Establish Incremental Goals & Measures
Validate Improvements Achieved
Develop Systems to Sustain Improvements
Current Performance
Opportunities for Improvement (OFI’s)
Performance Objectives
STRATEGIC PERFORMANCE EXCELLENCE
Dietary Bobbie Lindsey
I. Measure Name: ServSafe TrainingMeasure Description: ServSafe is a food and beverage safety training and certificate program administered by the National Restaurant Association Type of Measure: Quality Assurance
Results
TargetBaseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
1Q201793%
14/15
100% 100% 100% 100% 100%
Actual 93%14/15
93%14/15
Data Analysis: The data indicates that we fell short of our goal of 100% certification by 7%; 1 employee out of 15 was not trained.
Action Plan: Continue to offer the ServSafe class yearly, or as needed, to ensure that all staff remain certified. I would like to include other staff members in the hospital that handle food for patients.
Comments: A ServSafe class will be held this fiscal year for employees whose certificates are scheduled to expire.
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STRATEGIC PERFORMANCE EXCELLENCE
Facilities Mark Faulkner
I. Measure Name: Life Safety Standard Compliance for Above Ceiling WorkMeasure Description: Analyze compliance to Policy FP-9 involving Above Ceiling Work to verify conformance to life safety standards involving maintaining fire and smoke ratings of the space above the ceilings throughout the Hospital. Type of Measure: Performance Improvement
Results
TargetUnit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
Number of ceiling
inspections
1Q2017100%(New
Measure)
100% 100% 100% 100% 100%
Actual 100%15/15
100%15/15
Methodology: The Director of Facilities (DOF) and the Plant Engineering Supervisor will perform physical checks of areas where above ceiling work is scheduled as well as other areas where above ceiling work is suspected to have occurred. Both approved and unapproved above ceiling work will be inspected and tracked separately and locations of the inspections noted on the tracking sheet. In accordance with Policy FP-9, 100% of scheduled above ceiling work will be inspected each month. In addition to scheduled checks, 15 unscheduled quarterly checks will be performed in areas as determined by the DOF and PES. The DOF will analyze the data monthly as to the success of the PI initiative
The numerator for both scheduled and unscheduled checks will be the total number of areas inspected with the denominator being the total number of scheduled and unscheduled inspections where no deficiency to the integrity of the rating is observed during the inspection. Scheduled and unscheduled above ceiling work inspections will be tracked separately. The performance percentage (performance ratio) for both scheduled and unscheduled above ceiling work inspections will be the numerator divided by the denominator.
Data Analysis: During the 1Q2017, 15 ceiling checks were performed. Of the 15 checks performed, all 15 were in compliance with life safety standards; therefore the overall compliance rate for the quarter is 100%.
Action Plan: None needed at this time.
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STRATEGIC PERFORMANCE EXCELLENCE
Health Information Management Michelle Welch, RHIT
Regulatory and Compliance Standards in DocumentationEnsuring Fiscal Responsibility in Documentation and Billing Practices
Indicator and Rationale for Selection 1Q2017 2Q2017 3Q2017 4Q2017 YTDIdentification Data 100%
32/32100%32/32
Medical History, including chief complaint; HPI; past, social & family hx., ROS, and physical exam w/in 24 hrs., conclusion and plan.
100%32/32
100%32/32
Summary of patient’s psychosocial needs as appropriate to the patients *
94%30/32
94%30/32
Psychiatric Evaluation in patient’s record w/in 24 hrs. of admission
100%32/32
100%32/32
Psychiatric Evaluation authenticated within 60 hours of admission
84%27/32
84%27/32
Physician (TO/VO w/in 72 hrs.) 91%162/179
91%162/179
Evidence of appropriate informed consent
93%26/28
4 Declined
93%26/28
4 Decline
dClinical observations including the results of therapy.
100%32/32
100%32/32
Nursing discharge Progress Note with time of discharge departure
100%32/32
100%32/32
Consultation reports, when applicable100%10/1022 N/A
100%10/10
22 N/A
Advance Directive Status on admission and SW follow up after
94%30/32
94%30/32
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STRATEGIC PERFORMANCE EXCELLENCE
Indicator and Rationale for Selection 1Q2017 2Q2017 3Q2017 4Q2017 YTDNotice of Privacy 100%
32/32100%32/32
Chart Completion w/in 30 days of discharge date/discharge summary completed within 30 days
97%31/32
97%31/32
Discharge Packet sent to follow up provider within 5 days of discharge.
100%32/32
100%32/32
*The parameters for this measure will be changed to meet applicable goals as defined by Director of Social Work. The current measure is more stringent than regulatory standards dictate.
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STRATEGIC PERFORMANCE EXCELLENCE
Human Resources Tamra Hanson
I. Measure Name: Employee work-related injuries (treatment related) and incidents (no treatment).Measure Description: Staff safety is central to DDPC. While staff safety events may not be completely eliminated, events can be reduced by reviewing trends related to injuries.
Type of Measure: Performance Improvement
Results1Q2017
(Baseline) 2Q2017 3Q2017 4Q2017 YTD
# of Staff Injuries 9 9
# of Staff Incidents 7 7
Data Analysis: In the 1st quarter, DDPC had 9 staff injuries and 7 staff incidents; 9 were patient related, 1 fall/slip/trip, 1 repetitive task, 4 self-injury, and 1 equipment.
Action Plan: A baseline has been established. We will start reporting at IPEC to inform leadership of staff safety events and trending data to look for opportunities to reduce the likelihood of injuries in the future.
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STRATEGIC PERFORMANCE EXCELLENCE
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STRATEGIC PERFORMANCE EXCELLENCE
II. Measure Name: Vacancies filled within 45 days of posting.Measure Description: The hospital will maintain an adequate workforce to maintain safety and provide therapeutic care for patients. Type of Measure: Performance Improvement
Results
Target
Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTDFY2016 Average 100% 100% 100% 100% 100%
Vacancy Rate % 15% 14% 14%
# Vacancies
Posted14 8 8
# Vacancies
Filled Within 45
Days
6 3 3
% Posted & Filled
Within 45 Days
40% 38% 38%
Data Analysis: Increase percentage rate of filled quarterly posted vacancies within 45 days of posting.
Action Plan: This is new data collection in an effort to reduce extended time periods of vacant positions
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STRATEGIC PERFORMANCE EXCELLENCE
1Q2017 2Q2017 3Q2017 4Q20170%
10%20%30%40%50%60%70%80%90%
100%
0.38
Vacancies Filled Within 45 Days of Posting
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STRATEGIC PERFORMANCE EXCELLENCE
III. Measure Name: Performance Evaluations completed by due date.Measure Description: DDPC evaluates staff based on performance expectations that reflect their job responsibilities. This evaluation is documented in the HR Personnel File by is due date. Type of Measure: Performance Improvement
Results
Target
Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTDMonthly Average FY2016
100% 100% 100% 100% 100%
# Due 43 49 49
# Completed
on Time17 10 10
% Completed
on Time38% 20% 20%
Data Analysis: The FY 2016 average percentage of performance evaluations submitted by the due date was at 38%; the 1st quarter of FY 2017 is at 20% an 18% decrease. We are below the target of 100%.
Action Plan: This is new data collection. We will start reporting at IPEC so that managers are aware of the data. This will hopefully continue increasing our compliance rates.
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STRATEGIC PERFORMANCE EXCELLENCE
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STRATEGIC PERFORMANCE EXCELLENCE
Infection Control Heather Brock, RN
I. Measure Name: Hospital Acquired InfectionsMeasure Description: Surveillance data will continue to be gathered on the following hospital acquired infections: UTI, URI, LRI, and Skin. Data will be reviewed monthly and reported quarterly.Type of Measure: Quality Assurance
ResultsUnit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
Target: 0 HAI
# of HAI per quarter
FY 20120 HAI 1 HAI 1 HAI
Data Analysis: There were one hospital acquired infections for 1st quarter FY2017, and 0 hospital acquired infection for 4th quarter FY2016.
FY
2014-2016 Hospital Acquired Infections
Type of Infectio
n
1Q 201
5
1Q201
6
1Q 201
7
2Q 201
5
2Q201
6
2Q 201
7
3Q 201
5
3Q201
6
3Q 201
7
4Q 201
5
4Q201
6
4Q 201
7UTI 0 0 0 0 0 0 0 0 0URI 0 0 0 0 0 0 0 0 0LRI 0 0 1 0 0 0 0 0 0Skin 0 0 0 0 0 0 1 0 0Totals 0 0 0 0 0 0 1 0 0Infection Rate 0 0 0.26 0 0 0 0.28 0 0
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H. A. Infections FY 2015 FY 2016 FY 20171st Quarter H.A.I. Rate 0 0 12nd Quarter H.A.I. Rate 0 03rd Quarter H.A.I. Rate 0 14th Quarter H.A.I. Rate 0 0Average H.A. Infection Rate 0 0.25 1
STRATEGIC PERFORMANCE EXCELLENCE
Infection Rate per 1000 patient days: Total number of infections per unit x 1000 = % Total number of inpatient days
1st Quarter 2015 = 3256 1st Quarter 2016 = 3361 1st Quarter 2017=38892nd Quarter 2015 = 3550 2nd Quarter 2016 = 3508 2nd Quarter 2017=3rd Quarter 2015 = 3453 3rd Quarter 2016 = 3587 3rd Quarter 2017=4th Quarter 2015 = 3422 4th Quarter 2016 =3584 4th Quarter 2017=
II. Measure Name: Patient & Family Education on Hand Hygiene/Cough EtiquetteMeasure Description: Prior to discharge, a questionnaire will be distributed to each patient that includes the following questions:
D1: I received information on how to stay healthy by washing my hands
D2: I received information on how to cover my cough or sneeze to prevent the spread of illness
Type of Measure: Performance Improvement
ResultsUnit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
Target:D1 90%
Quarterly response rate
“agree/strongly agree” for D1 &
D2 is set at 90%
2012: D1 response rate: 80%
86% 86%
Target:D2 90%
2012: D2 response rate: 80%
86% 86%
Data Analysis: First quarter response rate for question D1 was 86%, a decrease of 7% from the previous quarter. First quarter response rate for question D2 was 86%, a decrease of 4% from the previous quarter.
Action Plan: For FY2017, the goal has been increased to 90% compliance rate.
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STRATEGIC PERFORMANCE EXCELLENCE
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STRATEGIC PERFORMANCE EXCELLENCE
III. Measure Name: Healthcare Worker (HCW) Hand HygieneMeasure Description: HCW hand hygiene is being monitored on each unit with a minimum of 10 “direct observations” during a 24 hour period per month. This is currently the “gold star” and the most reliable method for assessing adherence rates.Type of Measure: Performance Improvement
ResultsUnit Baseline
1Q2017 1Q2017 2Q2017 3Q2017 4Q2017 YTD
Target: sustained level of compliance that approaches 90%
HCW hand hygiene
compliance rate per unit per quarter
Knox:93% 93% 93%
Hamlin:87% 87% 87%
Chamberlain: 93% 93% 93%
Data Analysis: Baseline data collected for 1st quarter FY2017.
Action Plan: Continue to monitor HCW hand hygiene compliance per CDC guidelines.
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STRATEGIC PERFORMANCE EXCELLENCE
Goal: To have a sustained level of compliance that approaches 100%
IV. Measure Name: Influenza ImmunizationsMeasure Description: The standard goal is to have a sustained level of compliance that approaches and achieves the 90% compliance rate established in the National Flu Initiative for 2020. Employee flu vaccination compliance is measured annually.Type of Measure: Performance Improvement
ResultsUnit Baseline FY 2016 FY 2017 FY 2018 FY 2019 FY 2020
Target: 90%
Percent of employees
who receive the flu
vaccination
FY 201581%
69%
Action Plan: Continue to educate staff and promote influenza vaccinations.
Comments: DDPC is currently hosting its annual Flu Clinic for 2016-2017.
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STRATEGIC PERFORMANCE EXCELLENCE
Medical Staff Dr. Michelle Gardner
I. Measure Name: Restraint DocumentationMeasure Description: Proper documentation is the only way to demonstrate and provide a record that the clinical criteria and assessments for seclusion/restraint have been met. Documentation is critical for patient care/safety, as it validates the care that was provided.Type of Measure: Performance Improvement
ResultsTarget
RestraintsBaseline (March 2015)
1Q2017
2Q2017
3Q2017
4Q2017
YTD 2017
Total Restraints 12 39 39Is order complete? N/A 89% 89%On order, is the intervention stated in behavioral terms?
100% 87% 87%
100%Does the time of the orders match interventions and times on Nursing forms?
N/A 94% 94%
Is Medical Staff Seclusion and Restraint Progress Note complete (both sides)?
100% 65% 65%
Is the time of the 1 hour face to face within an hour of the event? 100% 100
% 100%
If PA, did PA consult with attending? 100% 81% 81%Are the details of the event similar on all forms? 100% 93% 93%
Did the medical provider participate in the Seclusion and Restraint treatment plan review?
N/A 100% 100%
Overall Compliance 100% 87% 87%
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STRATEGIC PERFORMANCE EXCELLENCE
Goal 100% Compliance with Medical Staff Documentation
Data Analysis: There were 39 restraints in the 1st quarter. The overall compliance rate decreased 4%: from 93% in 4th quarter FY2016, to 89% in 1st quarter FY2017.
Action Plan: The plan moving forward is to continue to monitor compliance with the above data element and to discuss and address non-compliance with the medical staff.
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STRATEGIC PERFORMANCE EXCELLENCE
II. Measure Name: Seclusion DocumentationMeasure Description: Proper documentation is the only way to demonstrate and provide a record that the clinical criteria and assessments for seclusion/restraint have been met. Documentation is critical for patient care/safety, as it validates the care that was provided.Type of Measure: Performance Improvement
ResultsTarget
SeclusionsBaseline (March 2015)
1Q2017
2Q2017
3Q2017
4Q201
7
YTD 2017
Total Seclusions 7 12 12Is order complete? N/A 72% 72%On order, is the intervention stated in behavioral terms? 92% 56% 56%
100%Does the time of the orders match interventions and times on Nursing forms?
N/A 100% 100%
Is Medical Staff Seclusion and Restraint Progress Note complete (both sides)?
100% 44% 44%
Is the time of the 1 hour face to face within an hour of the event? 100% 100% 100%
If PA, did PA consult with attending? 92% 100% 100%Are the details of the event similar on all forms? 100% 100% 100%
Did the medical provider participate in the Seclusion and Restraint treatment plan review?
N/A 100% 100%
Overall Compliance 96% 84% 84%
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STRATEGIC PERFORMANCE EXCELLENCE
Goal: 100% Compliance with Medical Staff Documentation
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STRATEGIC PERFORMANCE EXCELLENCE
Data Analysis: There were 12 seclusions in the 1st quarter. The overall compliance rate decreased 12%: from 96% in 4th quarter FY2016 to 84% 1st quarter FY2017.
Action Plan: The plan moving forward is to continue to monitor compliance with the above data elements and to discuss and address non-compliance with the medical staff.
III. Measure Name: All elements of a medication order are complete. Measure Description: To promote safe medication ordering by defining the required elements of a complete medication order.Type of Measure: Performance Improvement
Data Elements Baseline 4Q2016 1Q2017 2Q2017 3Q2017 4Q2017 Total
Compliance# of Medication orders reviewed 245 258 258
Medication order sheet has patient name, DOB and hospital number ID (2 patient identifiers)?
100% 100% 100%
Date and time of the order 99% 99% 99%Medication name 99% 100% 100%Medication dose 96% 97% 97%Route of administration 94% 97% 97%Frequency of administration and/or dosing interval
92% 98% 98%
Indication for use 90% 96% 96%Authorized prescribers signature and credentials 97% 98% 98%
Telephone orders completed, signed, dated and timed w/in 72 hr.
97% 100% 100%
Overall Compliance 93% 98% 98%
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STRATEGIC PERFORMANCE EXCELLENCE
Data Analysis: Six data elements were found to be below the established goals of 100% for the 1st quarter; however, all have shown an improvement from 4th quarter FY2016. The data elements remain above the threshold of 90% compliance. Action Plan: Continue to monitor.
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STRATEGIC PERFORMANCE EXCELLENCE
Nursing Janet Babcock, RN
I. Measure Name: Restraint Audits – Patient SafetyMeasure Description: Proper documentation is the only way to demonstrate and provide a record that the clinical criteria and assessments for seclusion/restraint have been met. Documentation is critical for patient care/safety, as it validates the care that was provided. The audits were initiated January of 2015. Type of Measure: Performance Improvement
Results
Target Data ElementsBaselin
e4Q2016
1Q2017
2Q2017
3Q2017
4Q201
7YTD
100%Compliance
# of Events 35 39 391. Each order obtained within 15 minutes of the intervention?
83% 96% 96%
4. Is Form 408 Nursing Seclusion/Restraint Progress Note complete?
95% 83% 83%
5. On Form 408 Nursing Seclusion/Restraint Progress Note, Form 470 Nursing Assessment Protocol for Seclusion and Restraint, and Physician Orders do times match for interventions initiated and time of events?
97% 94% 94%
9. Are details of event similar on all forms without discrepancies 408, 409, and Order sheets?
97% 93% 93%
10. Is Form 470 Nursing Assessment Protocol for Seclusion and Restraint completed?
96% 100% 100%
15. Were debriefings DB1 & DB2 completed at
99% 89% 89%
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STRATEGIC PERFORMANCE EXCELLENCE
appropriate times?16. Is patient debriefing in the chart? 89% 93% 93%
Target Data ElementsBaselin
e4Q2016
1Q2017
2Q2017
3Q2017
4Q201
7YTD
100%Compliance
19. Was Form 470 TX Focused Treatment Plan Review completed within 24 hours?
88% 91% 91%
Overall Compliance 93% 92% 92%
Data Analysis: The 1st quarter FY2017 shows a compliance rate of 92%, a 1% decrease from new baseline. Four elements increased and 4 elements decreased with negligible statistical impact. There were 39 total restraint events this quarter with unit totals of July: Knox 3, Hamlin 2, Chamberlain 6, for a total all 11; August: Knox 2, Hamlin 4, Chamberlain 8, for a total of 14; September: Knox 5, Hamlin 2, Chamberlain 7, for a total of 14. Numerous restraint events can be contributed to same-patient manual holds over the course of the quarter. Unit totals for 1 st
Quarter overall compliance are: Knox 94% with 10 events, Hamlin 94% with 8 events, and Chamberlain 89% with 21 events. Nursing documentation will be extracted and separated from Medical Staff documentation except for one data element 9, “Are details of event similar on all forms without discrepancies, 408, 409, and Order sheets,” as this reflects equivalent documentation responsibilities.
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STRATEGIC PERFORMANCE EXCELLENCE
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STRATEGIC PERFORMANCE EXCELLENCE
Action Plan: Nursing staff remains below goal and will continue to audit the documentation of patient restraints on a monthly basis and re-evaluate quarterly and yearly. Nursing will compare data gathered from Meditech reporting to ensure all coercive events are captured. There is a possibility that prior to beginning this cross-check in December 2015, events were not captured for data collection.
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STRATEGIC PERFORMANCE EXCELLENCE
II. Measure Name: Seclusion DocumentationMeasure Description: Proper documentation is the only way to demonstrate and provide a record that the clinical criteria and assessments for seclusion/restraint have been met. Documentation is critical for patient care/safety, as it validates the care that was provided.Type of Measure: Performance Improvement
Results
Target Data ElementsBaselin
e4Q2016
1Q2017
2Q2017
3Q2017
4Q2017 YTD
100% Compliance
# of Events 13 10 101. Each order obtained within 15 minutes of the intervention?
91% 89% 89%
4. Is form #408 Nursing Seclusion/Restraint Progress Note complete?
82% 89% 89%
5. On Form #408 Nursing Seclusion/Restraint Progress Note, Form #470 Nursing Assessment Protocol for Seclusion and Restraint, and Physician Orders do times match for interventions initiated and time of events?
100% 100% 100%
9. Are details of event similar on all forms without discrepancies #408, #409, and Order sheets?
100% 100% 100%
10. Is Form # 470 Nursing Assessment Protocol for Seclusion and Restraint completed?
88% 100% 100%
11. On Form # 407RN 2 Hour Seclusion and Restraint Breaks 2 hour breaks are completed at
84% 100% 100%
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STRATEGIC PERFORMANCE EXCELLENCE
appropriate intervals and signed by RN?
Results
Target Data ElementsBaselin
e4Q2016
1Q2017
2Q2017
3Q2017
4Q2017 YTD
100% Compliance
12. On Form #407RN 2 Hour Seclusion and Restraint Breaks is time ended for S/R completed and signed by RN
59% 89% 89%
13. On Form #407 Seclusion & Restraint Monitoring and Assessment 15 minute checks are completed at appropriate intervals, with Pt’s behavior documented in behavioral terms as it pertains to release criteria, times, dated, and initialed by staff?
94% 72% 72%
14. On Form #407 Seclusion & Restraint Monitoring and Assessment did each staff member that initialed 15 minute checks complete last page of form with signature and title?
61% 68% 68%
15. Were debriefings DB1 & DB2 completed at appropriate times?
100% 83% 83%
16. Is patient debriefing in the chart? 75% 100% 100%
19. Was Form # 470 TX Focused Treatment Plan Review completed within 24 hours?
86% 83% 83%
Overall Compliance 85% 89% 89%
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STRATEGIC PERFORMANCE EXCELLENCE
Data Analysis: First quarter FY2017 comparison to fourth quarter FY2016 (new baseline) shows 89%; a 4% increase; 6 elements increased, 4 elements decreased, and 2 stayed the same. There were 10 total seclusion events this quarter with totals of July: Knox 1, Hamlin 1, Chamberlain 1, for a total of 3; August: Knox 0, Hamlin 0, and Chamberlain 2, for a total of 2; September: Knox 4, Hamlin 1, Chamberlain 0, for a total of 5. Unit totals for 1Q2017 overall compliance are: Know 83% with 5 events, Hamlin 96% with 2 events, and Chamberlain 90% with 3 events.
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STRATEGIC PERFORMANCE EXCELLENCE
Action Plan: Nursing staff remains below goal and will continue to audit the documentation of patient seclusions on a monthly basis and re-evaluate quarterly and yearly. Nursing documentation will be extracted and separated from Medical Staff documentation except for data element 9, “Are details of event similar on all forms without discrepancies, 408, 409, and Order Sheets?” as this reflects equivalent documentation responsibilities. Nursing will compare data gathered from Meditech reporting to ensure all coercive events are captured. There is a possibility that prior to beginning this cross-check in December that events were not captured for data collection.
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STRATEGIC PERFORMANCE EXCELLENCE
III. Measure Name: Combined Coercive Event Legal Guardian Debriefing NotificationMeasure Description: Legal guardian questions are separated from aggregate data at this time; it is of great importance that legal guardians be made aware of coercive events and the subsequent debriefing with the patient to encourage participation and possible avenues to avoid future coercive events. Rather than reporting percentages, actual numbers are reflected in the results. These are a combination of both restraint and seclusion events. Type of Measure: Performance Improvement
1Q2017
Patient Unit# of Coercive Events
Knox15
Hamlin10
Chamberlain
24
17. Was legal guardian or agent made aware of time of debriefing?
Yes: 8No: 0N/A: 7
Yes: 3No: 3N/A: 4
Yes: 14No: 9N/A: 1
18. Did legal guardian or agent attend debriefing?
0/8 attended
0/3 attended
1/14attended
Description of Information: In the 1st quarter of FY2017, there were 25 guardian notifications completed post-coercive event to inform of approaching patient debriefing. There were 12 instances in which guardians should have been notified and were not, and 12 occurrences in which legal guardian notification was not applicable to the situation; these patients would have no legal guardian other than themselves. Out of the 25 completed guardian notifications, one guardian attended a patient’s debriefing. The lack of guardian participation in this process may possible be attributed to time constraints as the debriefing will take place no later than 16 hours following the event, or a number of factors that may affect patient/guardian relationships.
Action Plan: Nursing has separated this information from the rest of seclusion and restraint reporting data to observe for trends for corrective action. It is the Nurse Supervisor’s responsibility to notify the guardian and debrief with the patient. Nursing administration will address guardian notification and implications for lack of notification with nurse supervisors.
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Outpatient Services/Forensics Robyn Fransen, LSW-C
I. Measure Name: Timeliness of Institutional Reports and Annual Reports. Measure Description: All annual reports are due yearly by December 31, as required by Maine Statute Title 15. Institutional reports are due within 10 days after receiving notice of a filed petition. A tardy filing of an institutional report would delay a forensic patient’s evaluation and ability for increased privileges, modified release, and ultimately release and discharge from the custody of the Commissioner. Type of Measure: Performance Improvement
Results
Target Data ElementsBaseline FY2016
1Q 2017
2Q 2017
3Q 2017
4Q 2017 YTD
100% Compliance
Total # of Reports Due? 8 2 2# of Institutional Reports Due? 3 2 2
Institutional Report submitted within 10 days of notice of hearing being received by DDPC?
33% 100% 100%
# of Annual Reports Due 5 0 0%Annual Report submitted by December 31, 2015? 80% N/A N/A
Overall Compliance of reports submitted by due date.
63% 100% 100%
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Data Analysis: The data element “Institutional Report Submitted within 10 days of notice of hearing being received by DDPC was at 100% for 1Q2017, which is up from the baseline of 33% for FY2016. The data element “Annual Report Submitted by December 31, 2016” is not applicable at this time. The overall compliance increased from 63% to 100% from FY2016 to 1Q2017.
Action Plan: Continue to track and monitor the completion and submission of the Institutional and Annual reporting, using a Forensic Timeline Report which will assist in keeping staff notified of upcoming dates. It has been determined that the notice of hearing was not being distributed to all members of the forensic team and will need to be date stamped upon receipt and distributed immediately so that IR’s can be completed on time.
II. Measure Name: Timeliness of Medical Record Documentation for Outpatient Services.Measure Description: All progress notes are promptly filed and readily available in the patient’s medical record. This information is necessary to monitor the patient’s condition. It must be in the patient’s medical record. Health care staff involved in the patient’s care must be able to access/retrieve this information in order to monitor the patient’s condition and provide appropriate treatment and client services; therefore, necessary information must be entered and available in the medical record promptly
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Type of Measure: Performance Improvement
Results
Target Data elements BaselineFY2016
1Q2017
2Q2017
3Q 2017
4Q2017 YTD
90%
# of Notes 778 173 173Psychiatric notes entered within 72 hours? 83% 89% 89%
Nursing notes entered within 72 hours? 98% 100% 100%
Social Work notes entered within 72 hours? 88% 97% 97%
Psychology notes entered within 72 hours? 78% 83% 83%
Overall Compliance 89% 94% 94%
Data Analysis: Data elements “Psychiatric Notes Entered within 72 hours” and “Nursing notes entered within 72 hours” both increased in compliance from last quarter. “Social Work notes entered within 72 hours” decreased slightly from 100% to 97% and “Psychology notes entered within 72 hours” decreased from 91% to 83%. Overall compliance decreased slightly from 96%
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to 94%, but still remains above the 90% compliance rate. Some of the decreases may be attributed to change in staff and addition of new staff to outpatient services.Action Plan: Continue to audit notes on a monthly basis, remind staff of the policy for completing notes, and hold monthly meetings during which documentation will be an ongoing discussion. Psychiatry and Psychology will be notified that their compliance rate continues to be under the 90% goal.
III. Measure Name: Timeliness of Initial and Annual Assessment Documentation for Outpatient ServicesMeasure Description: All initial and annual assessments (psychiatric, nursing, social work) are completed and filed in the patient’s medical record and in the electronic medical record within 30 days of the patient’s admission and annual date. This information is necessary to monitor the patient’s condition. It must be in the patient’s medical record. Health care staff involved in the patient’s care must be able to access/retrieve this information in order to monitor the patient’s condition and provide appropriate treatment and client services; therefore, necessary information must be entered and available in the medical record promptly
Results
Target Data elements BaselineFY2016
1Q 2017
2Q 2017
3Q 2017
4Q 2017
100%
# of Assessments 8 5 5Psychiatric assessment complete and entered within 30 days? 50% 100% 100%
Nursing assessment complete and entered within 30 days? 88% 100% 100%
Social Work assessment complete and entered within 30 days? 88% 100% 100%
Overall Compliance 75% 100% 100%
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Data Analysis: There were four patients with annual assessments due and one new patient opened during 1Q2017, all assessments were completed on time. This is an increase from the baseline of 75% overall compliance during FY2016.
Action Plan: Will continue to audit all assessments on a monthly basis, flagging any upcoming or currently due assessments, and setting weekly reminders on outlook to begin one month before annual date to remind staff of the upcoming due date. If we remain at 100% compliance, then this performance improvement measure can be discontinued and a new measure will be determined.
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Pharmacy Services Michael Migliore, RPh
I. Measure Name: Medication Management MonitoringMeasure Description: Documentation of Clinical InterventionsType of Measure: Performance Improvement
UnitBaseline 4Q2016 1Q2017 2Q2017 3Q2017 4Q2017 YTD
Actual Rx 397 867 867
Data Analysis: The number of clinical interventions continues to increase, largely due to the development of new monitoring programs. The pharmacy is now participating in monitoring all of the patients’ renal function, electrolyte levels, and metabolic parameters to find areas for medication use optimization. The data collection and recording system continues to be enhanced, further accounting for the increased interventions.
Action Plan: Continue current monitoring programs and adding others in DDPC’s continuing effort to strive for excellence in patient care.
Comments: The pharmacy team is working to institute a comprehensive metabolic monitoring initiative and a revised polyantipsychotic therapy monitoring program, so the number of interventions is only expected to increase.
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II. Measure Name: Medication Management MonitoringMeasure Description: The Psychiatric Emergency OrderType of Measure: Performance Improvement
Process Element No Yes 1Q2017
2Q2017
3Q2017
4Q2017 YTD
Reason for non-
complianceTarget Pharmacy received
PE orders2 100% 100% 100% 100% 100%
Actual 100% 100%Target Did RPh need to
resolve PE orders1 1 0% 0% 0% 0% 0% 1 simple
clarificationActual 50% 50%Target Were PE meds
Clearly identified when clarified
0 1 100% 100% 100% 100% 100%Actual 100% 100%
Target Was any PE written for up to 72 hours, stopped by writing “Discontinue Emergency Meds”?
0 0 100% 100% 100% 100% 100%Actual 100% 100%
Target Was a one-time PE intervention specified as an Emergency Med?
0 0 100% 100% 100% 100% 100%Actual 100% 100%
Target Did any Emergency Med not end in 72 hours?
0 2 0 0 0 0 0Actual 0 0
Target Was PE co-signed by psychiatrist if ordered by a PA?
N/A N/A 100% 100% 100% 100% 100%Actual N/A N/A
Data Analysis: There were two psychiatric emergencies declared during the quarter. One of them required a simple order clarification, but the rest of the orders were complete. The PE orders occurred when the pharmacy is closed, but all orders were clearly identified as emergency medication orders.
Action Plan: Continue to collect information on psychiatric emergencies. Improvements will be discussed at Pharmacy & Therapeutics Committee meetings as necessary.
Comments: This continues to be an area of focus for DDPC.
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III. Measure Name: Medication Management MonitoringMeasure Description: Shift the Variance occurred onMeasure Type: Performance Improvement
UnitsBaseline 4Q2016 1Q2017 2Q2017 3Q2017 4Q2017 YTD
Target
All
0 0 0 0 0 0Actual 11 30 30
7am-3pm 5 17 173-11pm 5 10 10
11pm-7am 2 3 3
Data Analysis: As expected, most variances occur during the day shift as this is when most medications are administered. The increase in variances is partly due to findings on the monthly medication room inspections being documented in this pathway, whereas in the past they had primarily been reported to the unit’s nursing supervisor. There was also a prolonged extenuating circumstance that required the creation of an entirely new medication dispensing and administration process, which expectantly contributed to the increased number of variances.
Action Plan: Pharmacy will continue to write variances as necessary that arise from findings in the medication room inspections, as it helps to address concerns on a timely basis and reinforces proper protocols. Nursing and pharmacy will continue to work together to address any concerns so that issues can be addressed before they reach the patient.
Comments: The staff continues to work to avoid variances whenever possible and continues to report them promptly as necessary. Education is provided promptly whenever needed.
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IV. Measure Name: Medication Management MonitoringMeasure Description: Cause of VarianceMeasure Type: Performance Improvement
Baseline 4Q2016 1Q2017 2Q2017 3Q2017 4Q2017 YTD
Target 0 0 0 0 0 0Actual 11 39 39
Two forms of patient ID not used 1 1Inaccurate check of MARNot Yellowed on MAR 1 1MD order issues 1 1MAR print out wrongNew order overlooked 2 2New order 1 1High Alert Med 2 2Pyxis loading error 1 1Med Overlooked 8 5 5Distractions 2 2 2Dispensing errorProcedure not followed 2 18 18Unclear order 1 1Transcription 4 4
Please note that the number of causal factors is discrete from the number of variances; each variance may have multiple causes.
Data Analysis: For the first quarter the most common contributing factor to medication variances was that procedures were not accurately followed. Many of these errors came from failure to appropriately label medications obtained by after-hours personnel from the night cabinet. The night cabinet is utilized when new, patient specific medications are ordered when the pharmacy is closed. Staff has been re-educated regarding the appropriate procedure and improvements have already been realized.
Action Plan: Pharmacy will continue to monitor the daily Pyxis activities to ensure proper handling of medications. An interdisciplinary team reviews the variances on both a monthly and as-needed basis so that any concerns can be quickly addressed and remedied. The reporting of variances, both actual and near miss’s, is increasing; while this does superficially appear as an increase in the number of variances, this should help to decrease medication
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errors overall, while enhancing education regarding the correct course of action in any given circumstance.
Comments: The variances and the related procedures for reporting and documenting them are continuously reviewed and discussed. DDPC will continue with its efforts to minimize variances and to educate staff as to how processes may be improved for optimal patient care.
V. Measure Name: Medication Management MonitoringMeasure Description: Type of VarianceType of Measure: Performance Improvement
UnitsBaseline 4Q2016 1Q2017 2Q2017 3Q2017 4Q2017 YTD
Target
All
0 0 0 0 0 0Wrong Dose 1 3 3Extra Dose 1 2 2Wrong Time 3 3Wrong Drug 2 2Wrong FormFrequencyOmission 7 10 10Wrong Patient 1 1ScheduleExpired Drug 1Procedure Not Followed 1 8 8Drug Not Loaded 1 1DispensingTotal 11 30 30
Methodology: The staff member that discovers the variance(s) writes the report and identifies what they believe to be the type and cause of the variance. The report is then circulated to Risk Management, Pharmacy, nursing unit supervisors, and other parties as necessary to be investigated. It is important to note that a single variance may encompass more than one type of error (for example, the wrong form of a drug may be given at the wrong time of day). For the purposes of the quarterly reports and for discussion at Pharmacy & Therapeutics meetings, the staff pharmacist compiles the variances and reports them to the rest of the committee for discussion.
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Data Analysis, Action Plan, and Comments: DDPC does a very good job of addressing variances promptly. Some of the variances have occurred due to a lack of communication, and increasing that communication is a main focus of the pharmacy staff. DPC will continue in its efforts to decrease the number of variances and provide re-education to the personnel involved as they arise.
VI. Measure Name: Medication Management – Controlled Substance Loss DataMeasure Description: Monthly Pyxis Controlled Drug DiscrepanciesType of Measure: Quality Assurance
UnitBaseline 4Q2016 1Q2017 2Q2017 3Q2017 4Q2017 YTD
AverageTarget
Rx8.8
month
0 0 0 0 0# of
discrepancies9.3
month9.3
monthNumber of
CS lost 0 0 0
Data Analysis: There were, on average, 9.3 controlled substance discrepancies per month for the quarter. This metric does not indicate the number of controlled substances lost; instead it illustrates the number of discrepancies that occur, which typically result from simple miscounts. No controlled substances were unaccounted for or lost during the quarter.
Action Plan: Pharmacy will continue to increase visibility and availability to the units to provide education regarding how controlled substance discrepancies occur and how they can be avoided.
Comments: We will continue to strive for a 0% loss of controlled substances.
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VII. Measure Name: Safety in Culture and Actions: Fiscal AccountabilityMeasure Description: Tracking of Dispensed Discharged PrescriptionsType of Measure: Quality Assurance
UnitBaseline FY2016 1Q2017 2Q2017 3Q2017 4Q2017 YTD
TargetAll
$1145.77 for 101 meds
0 0 0 0 0
Actual $157.165 Rxs
$157.165 Rxs
Data Analysis: The dispensed outpatient prescriptions this quarter occurred when the patients were being discharged or sent on leave to correctional facilities. In July, two prescriptions were filled for a patient being discharged until outpatient coverage could be reinstated; in August, a high-risk discharge was sent home with emergency medications for an existing health concern; and in September, two prescriptions were filled for a patient that was transferred to a medical hospital as they were unable to provide a necessary psychiatric medication to the patient during their stay.
Action Plan: Great strides have been made in reducing the cost of discharge medications. This task primarily falls to a pharmacy technician who functions closely with other departments, and at times other facilities, to ensure patients are receiving the benefits they are eligible for to obtain prescriptions outside of the hospital. DDPC continues to strive to only send discharge prescriptions with patients if they are truly necessary and will be utilized. A current focus is to reduce the number of medications that are going out with patients to the correctional facilities and not being used. Comments: DDPC continues to be successful with minimizing the costs of discharge medications. This remains a primary focus moving forward.
VIII. Measure Name: Safety in Culture and Actions – Veriform Medication Room AuditsMeasure Description: Monthly Comprehensive Audits of 45 CriteriaType of Measure: Quality Assurance
UnitBaseline FY 2016 1Q2017 2Q2017 3Q2017 4Q2017 YTD
TargetAll 85%
100% 100% 100% 100% 100%
Actual 100% 100%
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Methodology: The pharmacy performs comprehensive inspections of the medication rooms, central supply area, and the medical clinic on a monthly basis. These audits over 44 different criteria to ensure the medication rooms are kept in optimal condition for patient care. Patients’ medication profiles are also reconciled against the contents of their bulk-item bins to ensure they are adequately stocked and that discontinued orders have been appropriately removed.
Data Analysis: All inspections continue to be completed on time.
Action Plan: All inspections are now due by the third week of the month to ensure timely completion. Whenever possible the findings of the inspections are immediately communicated to the area supervisor(s) to provide immediate recognition of any deficiencies. There has been 100% on-time completion of all inspections since the revised process has been in place.
Comments: The corrective plan instituted during the last fiscal year continues to ensure 100% of all inspections are completed on time so that any concerns can be handled efficiently.
IX. Measure Name: Invalid OrdersMeasure Description: Incomplete/Invalid Orders
Type of Measure: Performance Improvement
January-16February-16
March-16April-16May-16June-16July-16
August-16September-16
October-16November-16December-16
0 20 40 60 80 100 120
025
3673
1443
5498
20
Monthly Totals of Invalid Orders
Background: With a zero tolerance policy for incomplete orders, every prescribed order must contain the drug name, strength, administration route, dosing frequency, provider signature, order time and date, accurate allergy and adverse drug reaction information, and indication. When the pharmacy receives an invalid order the staff pharmacist contacts the prescriber and/or the unit to rectify the noted deficiency or takes a telephone order clarification.
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Data Analysis: For 1Q2017, the number of invalid orders has significantly increased from the previous quarter. This is largely due to a number of invalid orders from several complicated late admissions written by after-hours prescribers that are less familiar with DDPC’s requirements. The most common invalidating factors continue to be missing indications and allergy information.
Action Plan: The staff pharmacist collects, records, and prepares a monthly report on the invalid orders and presents them to the Medical Director. Typically, once per quarter, the staff pharmacist goes to a Medical Staff meeting and presents the data to the prescribers to discuss any identified trends and challenges. The facility is looking forward to the implementation of the CoCentrix CPOE (computerized physician order entry) system later this year. CPOE will eliminate incomplete orders by not permitting providers to initiate an order that is not complete.
X. Measure Name: Polyantipsychotic Therapy (PAPT) TherapyMeasure Description: The use of two or more antipsychotic medications is discouraged as current evidence suggests little to no added benefit with an increase in adverse effects when more than one antipsychotic is used. The Joint Commission Core (TJC) Measure HBIPS-5 requires that justification be provided when more than one antipsychotic is used. Three appropriate justifications are recognized: 1) Failure of 3 adequate monotherapy trials, 2) Plan to taper to monotherapy (cross taper) and 3) Augmentation of clozapine therapy. This measure aligns itself with the HBIPS-5 core measure and requires the attending psychiatrist to provide justification for using more than one antipsychotic. In addition to the justification, the clinical/pharmacological appropriateness is also evaluated.Type of Measure: Quality Assurance
ResultsUnit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
TargetPolyantipsychotic
Therapy TBDTBD TBD TBD TBD TBD
Actual 34% 34%
Data Analysis: While justification has been a requirement for polyantipsychotic therapy (PAPT) it was completed on a case-by-case basis. It was decided to do so in a more formalized manner. Beginning in July, it was decided that data would be collected in a centralized manner and presented to the Pharmacy & Therapeutics to create a baseline data set of PAPT. For the
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quarter, 33.6% of patients at DDPC were receiving treatment with more than one antipsychotic, while 63% of the patients were receiving mono-antipsychotic therapy during the quarter.
Action Plan: DDPC will continue to develop the formalized PAPT tracking and reporting the findings to the Medical Director and prescribers at the facility. A formal, centralized process for PAPT will enable the facility to better optimize the patients’ therapies and identify trends and areas for improvement, all while striving for excellence in patient care.
XI. Measure Name: Metabolic MonitoringMeasure Description: Metabolic syndrome is a well-known side effect of second generation antipsychotics (SGAs) and represents a common comorbidity in the psychiatric population. The majority of patients prescribed antipsychotics are prescribed an entity from the SGA sub-class. The purpose of this is to ensure that DDPC is monitoring the patients it serves appropriately and to the best of its ability, while mitigating the consequences of metabolic syndrome as much as possible.Type of Measure: Performance Improvement
ResultsUnit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
Target Complete/ Up-to-date Metabolic
Parameters
TBD50% 65% 70% 75% 75%
Actual 70% 70%
Data Analysis: The pharmacy completed data collection of metabolic monitoring parameters for all patients in the hospital who were receiving atypical antipsychotics during the quarter. Data elements collected on all patients included BMI (Body Mass Index) and BP (blood pressure), in addition to lab results including HDL cholesterol, triglycerides, fasting blood sugar, and hemoglobin A1C. As this is a new program at DDPC the initial goal was 50%, and the facility has been able to surpass the predetermined goal with 69.8% of patients having complete and up-to-date monitoring parameters. The majority of the patients that were not up-to-date (30.2%) had refused blood draws multiple times or were newly admitted and had not had them ordered yet.
Action Plan: DDPC will continue to monitor for metabolic syndrome in DDPC’s patients, and particularly those using SGA therapy. The patients’ right to refuse assessment (weight, blood pressure and lab work) has been identified as a contributing factor to not being able to fully
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assess their metabolic status, explaining why the goal is not 100%. The pharmacy and the medical providers are both excitedly looking forward to the successfully implementation and maintenance of this very important clinical program, which is expected to meet the goals outlined above to continue striving for excellence in patient care. To aid providers with the task of maintaining up-to-date metabolic reviews of the patients, the pharmacy will maintaining a flow sheet that will be reported regularly, at least at the Pharmacy & Therapeutics Committee meetings, which will help identify which patients are due for lab work.
Comments: We are very pleased to find that he majority of DDPC’s patients are currently appropriately monitored for metabolic syndrome. The collaboration between pharmacy and the medical providers is expected to increase the patients with up-to-date metabolic parameters with the ultimate goal of reducing the development of comorbidities and allowing for the proper management of them in patients with existing metabolic conditions.
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XII. Measure Name: Turn-Around Time AuditMeasure Description: Comprehensive Pharmacy Services has several contractual parameters to meet to ensure timely and appropriate service to Dorothea Dix Psychiatric Center: 1) all orders will be delivered within 3 hours of request; 2) all STAT/ASAP orders will be delivered within 1 hour; 3) all requests for clinical pharmacy consultation will be responded to within 2 working days. Type of Measure: Quality Assurance
Time period: 7/1/2016 – 7/31/2016Turn Around Time Audit, daily afterhours activity (4pm-8am)
Total Orders 97Order Status
Routine 91 93.81%Stat 3 3.09%
Turn Around TimeAverage turn around (minutes) 34.97Average processing time (minutes) 8.44
Time period: 8/1/2016 – 8/31/2016Turn Around Time Audit, daily afterhours activity (4pm-8am)
Total Orders 115Order Status
Routine 110 95.6%Stat 5 4.34%
Turn Around TimeAverage turn around (minutes) 56.54Average processing time (minutes) 10.85
Time period: 9/1/2016 – 9/30/2016Turn Around Time Audit, daily afterhours activity (4pm-8am)
Total orders 97Order Status
Routine 91 93.81%Stat 4 4.12%
Turn Around TimeAverage turn around (minutes) 43.77Average processing time (minutes) 8.93
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Data Analysis: The overnight pharmacy service provider met all requirements set forth in the contract.
Action Plan: All orders processed after hours are monitored every day by the staff pharmacist to ensure they are entered correctly and on a timely basis. Any issues that arrive during the review are addressed that day. The service provider sends reports at the end of the month for review. These processes will be continued.
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Social Services Tammy Cooper, LCSW
I. Measure Name: 30 Day Readmissions Modified Root Cause AnalysesMeasure Description: Once the hospital has identified potentially preventable readmissions, it is expected to conduct an in-depth review of the discharge planning process for a sample of such readmission (at least 10% of potentially preventable readmissions, or 15 cases/quarter, whichever is larger is suggested but not required), in order to determine whether there was an appropriate discharge planning evaluation, discharge plan, and implementation of the discharge plan.Type of Measure: Quality Assurance
Having identified factors that contribute to preventable readmissions, hospitals are expected to revise their discharge planning and related processes to address these factors.
Data Analysis: There were three readmissions within 30 days of discharge in the 1st quarter. There were no readmissions in July, two readmissions in August, and one readmission in September. Of the two readmissions in August, both of the 45 day Modified Root Cause analysis were due within the 1st quarter, with 100% compliance.
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Results
Target Data elements Baseline4Q2016
1Q2017
2Q2017
3Q2017
4Q2017 YTD
Readmissions within 30 days of discharge 2 3 3
Progressive Treatment Plan (PTP)readmissions within 30 days 1 2 2
45 day root cause analyses due within the quarter 2 2 2
100%
Compliance with completion of a 45 day modified root cause analysis for all 30 day readmissions
100% 100% 100%
STRATEGIC PERFORMANCE EXCELLENCE
II. Measure Name: Grievance Compliance and Documentation.Measure Description: Addressing grievances in a timely manner allows potential rights violations to be resolved quickly therefore allowing patients and staff to continue to focus on treatment. A Nurse Supervisor must speak with the patient within four hours of notification of the grievance. Social Services must deliver a response to the patient within five days, with five days more if the grievant is notified, and with agreement of the Patient Advocate. Measure Type: Performance Improvement
Results
Target Data elements BaselineFY 2016
1Q2017
2Q2017
3Q2016
4Q2017 YTD
100%
# of Events 46 13 13Unit Staff compliant with addressing grievance? 89% 92% 92%
Unit Staff completed form correctly (boxes checked, dated/timed, all signatures completed, Nurse Supervisor notified)?
63% 38% 38%
*Nursing Supervisor compliant with addressing grievance within 4 hours?
86% 92% 92%
Nurse Supervisor completed form correctly (boxes checked, dated/timed, all signatures completed, forwarded to Social Worker)?
61% 31% 31%
*Social Worker compliant with addressing grievance within 5 days or within 5 more days if extension is requested?
100% 100% 100%
*Overall Compliance of Nursing Supervisor and Social Worker addressing grievance
93% 96% 96%
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Element 1: Unit Staff compliant with addressing grievance Element 2: Unit Staff completed form correctly and notified Nurse Supervisor Element 3: Nurse Supervisor addressed grievance within 4 hours Element 4: Nurse Supervisor completed form correctly and forwarded to Social Worker Element 5: Social Worker addressed grievance within 5 days or more than 5 days if
extension is requested Element 6: Overall Compliance of Nursing Supervisor and Social Worker Addressing
Grievance
Data Analysis: The data element of “Overall Compliance of Nursing Supervisor and Social Worker addressing grievance” has increased in compliance from 92% to 96% from 4th quarter FY2016 to 1st quarter FY2017. The data element “Nurse Supervisor compliant with addressing grievance within 4 hours” increased from 83% to 92%. Data is also tracked for unit staff addressing grievances and that decreased from 100% to 92%, and forms completed correctly by unit staff decreased from 50% to 38%.
Action Plan: There are non-compliance concerns with addressing and completing grievance forms across unit staff and nurse supervisors. A new grievance policy is being completed during the 2nd quarter with separate forms for complaints and grievances, which will address some of the challenges of filling out the forms correctly.
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Staff Education and Development Jenny Bamford-Perkins, MSN, RN
I. Measure Name: Mandatory Staff EducationMeasure Description: Both direct and non-direct care employees of Dorothea Dix Psychiatric Center are required to complete monthly mandatory staff education. The Staff Education Department will conduct monthly audits using the education database. Type of Measure: Performance ImprovementMethodology: The numerator will be the number of staff that completed their monthly education requirements for the quarter and the denominator will be the total number of staff for the quarter. The goal is to have 100% compliance of monthly education requirements by the last quarter of FY2017.
Learning Packets Due Goal 1Q2017 2Q2017 3Q2017 4Q2017
Hand-Off 100% 86%191/222
DM Risk 100% 82%121/147
Pain 100% 88%66/75
Death/Dying 100% 79% 116/146
Diversity 100% 81% 182/224
CAUTI's 100% 60%34/57
Anticoagulation 100% 56%32/57
Medication Safety 100% 54% 31/57
Glucometer Recert 100% 55%51/92
AMD 100% 45% 68/151
Evacuation Chair 100% 81% 179/222
On Time 74% 1071/1450
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Data Analysis: Overall analysis of the data reveals 74% compliance rate. The goal is for 100% compliance by the 4th quarter of FY2017.
Action Plan: Staff education will complete monthly audits, send monthly emails to staff that have not completed their learning packets, send a notice to supervisors by the 3 rd quarter to address their staff that are out of compliance, and alert the Superintendent of employees out of compliance by the 3rd quarter.
II. Measure Name: First Aid TrainingMeasure Description: Direct Care Staff will be able to render appropriate First Aid on a distressed or injured patient that is in seclusion, restraint, or during any other emergency event.Type of Measure: Performance ImprovementMethodology: The numerator will be the number of staff that attended First Aid training for the quarter and the denominator will be the number of staff scheduled to attend the First Aid training for the quarter. The goal is to have 100% of the required staff to have the training by the last quarter of FY 2017.
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ResultsUnit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
Target Number of Employees 0%
0% 30% 30% 60% 100%
Actual 0% 0%
Data Analysis: No employees were scheduled for First Aid in the 1 st quarter FY2017. In October 2016, scenarios specific to DDPC were revealed. An action plan is being developed to move into compliance with The Joint Commission standards, and data will be recorded in the next quarter.
Action Plan: Staff Education will begin staff education on the new standards beginning December 1, 2016.
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Therapeutic Services Lisa J. Hall, OTR/L
I. Measure Name: Direct Patient ContactMeasure Description: In order to receive effective treatment that will allow patients to return to a satisfying and meaningful life in their chosen community, staff must provide engagement, assessment and treatment that is targeted to meet their individual needs. The first step for performance improvement is increasing direct contact with patients.Each discipline will reach and maintain a 50% direct care productivity standard.Numerator: number of hours spent in direct contact with patientsDenominator: number of hours available to spend in direct contact with patients (scheduled hours, minus: vacation, sick, holiday and approved education hours). For full time employees scheduled hours will be defined as 37.5 unless approved for overtime. Salary staff that work more than 37.5 hours will continue to have 37.5 as their denominator, minus the time noted above.Type of Measure: Performance Improvement
Clinical Ancillary OTRecreatio
n1Q2017
Avg.July 42% 56% 48% 57% 51%August 43% 56% 47% 54% 50%September 39% 56% 49% 53% 49%1Q2017 Avg. 41% 56% 48% 55% 50%
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A. Measure Name: Direct Patient Contact - Occupational Therapy
ResultsUnit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
Target Percent of time spent
in direct patient contact.
36% March2015
50% 50% 50% 50% 50%
Actual 48% 48%
B. Measure Name: Direct Patient Contact - Therapeutic Recreation
ResultsUnit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
Target Percent of time spent
in direct patient contact.
53%March 2015
50% 50% 50% 50% 50%
Actual 55% 55%
C. Measure Name: Direct Patient Contact - Clinical Services
ResultsUnit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
Target Percent of time spent
in direct patient contact.
35%March 2015
50% 50% 50% 50% 50%
Actual 41% 41%
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STRATEGIC PERFORMANCE EXCELLENCE
D. Measure Name: Direct Patient Contact- Ancillary Services (Dietician, Chaplain, Peer Support, Treatment Habilitation Aide)
ResultsUnit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
Target Percent of time spent
in direct patient contact.
31%March 2015
50% 50% 50% 50% 50%
Actual 55% 55%
Data Analysis: With the exception of Clinical Services, all disciplines are within two percentage points of reaching the targeted goal. All departments have improved from baseline despite adding non-direct care responsibilities throughout the year.
Action Plan: Requesting a weekly time study for providers achieving less than 45 percent direct patient contact for the quarter and discussing barriers and ways to re-prioritize time. Continue to monitor direct care hours over the next six months to ensure treatment restructuring does not result in a decrease in services.
II. Measure Name: Timely Assessment / Improving Health OutcomesMeasure Description: In order to receive effective treatment that will allow patients to return to a satisfying and meaningful life in their chosen community; staff must provide engagement, assessment and treatment that is targeted to meet their individual needs. The formal beginning to a treatment relationship begins with an assessment of strengths and needs to guide the treatment plan. At each treatment plan meeting staff is expected to come prepared to share their area of expertise and propose what treatment offerings they will make available to the patient. To best guide treatment, discipline specific assessments must be complete and available in the patient record. Type of Measure: Performance Improvement
Competency
RestorationInitial
OTPsych. (30d)
Substance Abuse
(7d)Vocationa
l (7d)
OT Living Skills (10d)
Recreation
Received 5 29 4 5 11 8 29Completed on time 5 28 0 5 11 7 29Totals 100% 97% 0% 100% 100% 88% 100%
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STRATEGIC PERFORMANCE EXCELLENCE
A. Therapeutic Recreation Evaluations (QA Measure)Goal: All patients will have a therapeutic recreation evaluation in the medical record prior to the first treatment plan meeting.
Numerator: Recreation evaluations in the record by initial RTPDenominator: All initial RTP meetings held
Results
Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
TargetPercent of
Initial Therapeutic Recreation
evaluations in the record prior to the initial RTP.
49%2Q2016
90% 90% 90% 90% 90%
Actual 100% 100%
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STRATEGIC PERFORMANCE EXCELLENCE
B. Occupational Therapy Evaluations (QA Measure)Goal: All patients will have an occupational therapy evaluation in the record prior to the first treatment plan meeting. Numerator: OT evaluations in the record by initial RTP Denominator: All initial RTP meetings held
ResultsUnit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
TargetPercent of Initial OT
evaluations in the record prior to the initial RTP.
2Q201634%
90% 90% 90% 90% 90%
Actual 97% 97%
C. Substance Abuse Assessment (PI Measure)Goal: All patients will have a substance abuse assessment in the record within 7 calendar days of the referral. (Measure effective May 2016)
Numerator: Substance abuse assessments in record within 7 days of referralDenominator: All substance abuse assessment referrals received
Results
Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
TargetPercent of Initial Substance Abuse assessments in
the record within 7 days of
referral
50%May 2016
90% 90% 90% 90% 90%
Actual 100% 100%
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STRATEGIC PERFORMANCE EXCELLENCE
D. Occupational Therapy – Issue Specific Evaluation (PI Measure)Goal: All patients will have an issue specific occupational therapy evaluation in the record within 10 calendar days of the referral. Numerator: OT - Issue Specific evaluations in the record with 10 days of referral Denominator: All OT - Issue Specific evaluation referrals received
ResultsUnit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
TargetPercent of Initial
OT – Issue Specific
evaluations in the record
within 10 days of referral
83%May 2016
90% 90% 90% 90% 90%
Actual 88% 88%
E. Psychology – Issue Specific Evaluation (PI Measure)Goal: All patients will have an issue specific psychology evaluation in the record within 30 calendar days of the referral.
Numerator: Psychology – Issue Specific Evaluations in the record within 30 days Denominator: All Psychology – Issue Specific Evaluations received for review
ResultsUnit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
TargetPercent of Initial
Psychology assessments in
the record within 30 days of
referral
0%May 2016
90% 90% 90% 90% 90%
Actual 0% 0%
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STRATEGIC PERFORMANCE EXCELLENCE
F. Vocational Assessment (PI Measure)Goal: All patients will have a vocational assessment in the record within 7 calendar days of the referral.
Numerator: Vocational assessments in the record within 7 days of referralDenominator: All vocational assessment referrals received
Results
Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
TargetPercent of Initial
Vocational assessments in
the record within 7 days of
referral
100%May-June
2016
90% 90% 905 90% 90%
Actual 100% 100%
G. Competency Restoration Evaluations (PI Measure)Goal: All patients will have a competency restoration evaluation in the record prior to the first treatment plan meeting.
Numerator: Competency restoration evaluations in the record by initial RTPDenominator: All Initial RTP meetings held
Results
Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
TargetPercent of
Competency Restoration
evaluations in the record prior to the initial RPT
100%March 2016
100% 100% 100% 100% 100%
Actual 100% 100%
Data Analysis: OT/RT initial evaluation timeliness have met the requirements of the PI measure and will no longer be monitored. Vocational and Competency Restoration evaluations will be reclassified as QA measures.
Action Plan: Address provider performance issues with individual providers, and continue PI monitoring for referral based OT, RT, Psychology, and Substance Abuse evaluations.
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