· web viewconsumer surveys29 fall reduction strategies38 pain assessment42 s trategic performance...

QUARTERLY REPORT ON ORGANIZATIONAL PERFORMANCE EXCELLENCE

SECOND STATE FISCAL QUARTER 2017October, November, December 2016

Sharon L. Sprague Superintendent

February 14, 2017

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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.......................................................................................................................73Outpatient Services/Forensics...................................................................................84Pharmacy Services......................................................................................................90Social Services..........................................................................................................102Staff Education and Development............................................................................107Therapeutic Services................................................................................................110

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.

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

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

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.

JOINT COMMISSION

“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.

JOINT COMMISSION

Type and Cause of Injury by Month

Type - Cause Oct Nov Dec 2Q2017Accident 2 2Fall 1 1Other 0Patient to Patient Incident 3 4 7Self-Injurious Behavior 2 2Total 4 2 6 12

Severity of Injury by Month

Severity Oct Nov Dec 2Q2017No Treatment 4 1 3 8Minor First Aid 1 3 4Medical Intervention RequiredHospitalization RequiredDeath OccurredTotal 4 2 6 12

JOINT COMMISSION

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.

JOINT COMMISSION

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.

JOINT COMMISSION

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.

JOINT COMMISSION

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.

JOINT COMMISSION

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.

JOINT COMMISSION

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.

JOINT COMMISSION

Confinement Event Breakdown

Manual Hold

Mechanical Restraint

Locked Seclusion Grand Total % of Total

Cumulative %

MD1305 16 8 24 30.00% 30.00%MD2086 10 2 4 16 20.00% 50.00%MD1827 7 2 7 16 20.00% 70.00%MD2028 3 3 6 7.50% 77.50%MD1314 3 2 5 6.25% 83.75%MD1889 3 3 3.75% 87.50%MD487 2 1 3 3.75% 91.25%MD2092 1 1 2 2.50% 93.75%MD2087 1 1 2 2.50% 96.25%MD1689 2 2 2.50% 98.75%MD178 1 1 1.25% 100.00%Totals 49 4 27 80 100.00%

Unit MH LS Event Oct Nov DecChamberlain 22 13 Manual Hold 29 12 8Hamlin 15 8 Locked Seclusion 16 6 5Knox 12 6

JOINT COMMISSION

JOINT COMMISSION

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.

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.

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.

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).

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).

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.

JOINT COMMISSION

Multiple Antipsychotic Medications on Discharge (HBIPS 4)

Note: The Joint Commission discontinued this measure effective 6/30/2016.

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.

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

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.

2Q2017 ResultsContractor Program Administrator Summary of PerformanceAffiliated Laboratory Carolyn Dimek

Director of NursingAll indicators exceeded standards.

AMES Maine Mark FaulknerDirector of Facilities

Contract not utilized during timeframe.

Casella Waste Systems Mark FaulknerDirector of Facilities

All indicators met standards.

CES, Inc. Mark FaulknerDirector of Facilities

All indicators met or exceeded standards.

Comprehensive Pharmacy Services

Carolyn DimekDirector of Nursing

1 indicator did not meet standards: Services and required reports in Rider A to be provided in a timely manner. All other indicators met or exceeded standards.

Harriman Associates Mark FaulknerDirector of Facilities


Jackson & Coker Dr. Michelle GardnerClinical Director


Liberty Healthcare Physicians and/or Mid-Levels On Call

Dr. Michelle GardnerClinical Director


Liberty Healthcare Psychiatric Nurse Practitioner



Locum Tenens Psychiatry Dr. Michelle GardnerClinical Director


MD-IT Transcription Michelle WelchMedical Records Administrator


Northeast Cardiology Associates (NECA)



JOINT COMMISSION

Norris, Inc. Mark FaulknerDirector of Facilities

1 indicator did not meet standards: Compliance, as Quarterly Sprinkler System testing was not performed during this quarter as contracted. All other indicators met standards.

Otis Elevator Mark FaulknerDirector of Facilities


Penobscot Community Health Care (PCHC)


Indicator met standards.

Project Staffing Carol DavisBusiness Manager

All indicators exceeded standards.

Securitas Mark FaulknerDirector of Facilities


The Healing Staff Dr. Michelle GardnerClinical Director


UniFirst Mark FaulknerDirector of Facilities


Vista Staffing Dr. Michelle GardnerClinical Director


WBRC Architects Engineers Mark FaulknerDirector of Facilities

All indicators exceeded standards.

Worldwide Travel Staffing Carolyn DimekDirector of Nursing

Two indicators received a score of 1-2; 1 being didn’t meet standard, 2 being met standards: 1) Maintain a Safe & Therapeutic Environment for Patients and 2) Oversee Agency staff assigned to unit for compliance and competency related to safe and therapeutic patient care.

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.

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.

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%1%

0% 0%

Monthly CII Safe Vendor Receipt Report. Rx 0 Target:

Actual:00

00

0 0

Monthly Pyxis Unresolved Controlled Drug Discrepancies.

All 0/month

Target:Actual:

00

00

0 0

Medication Management Monitoring:Measures of drug reactions, adverse drug events and other management data.

Rx 2 Target:Actual:

00

02

0 0

Resource Documentation Reports of Clinical Interventions.

Rx 397 Actual: 867 1246

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:

October November December 2Q2017Number of Patients Discharged 11 7 7 25Number of Survey Responses 3 1 1 5Survey Response Rate 27% 14% 14% 20%

JOINT COMMISSION

CTM-3 Percent of Positive (agree or strongly agree):

October November December 2Q2017The 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.

100%3/3

100%1/1

0%0/1

80%4/5

When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.

100%3/3

100%1/1

100%1/1

100%5/5

When I left the hospital, I clearly understood the purpose for taking each of my medications.

100%3/3

100%1/1

100%1/1

100%5/5

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:

October November December 2Q2017Number of patients discharged 11 7 7 25Number of survey responses 0 3 6 9Survey response rate 0% 43% 86% 36%

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.

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.

JOINT COMMISSION

Dignity Domain1. 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.

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.

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.

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.

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.

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.

JOINT COMMISSION

Fall Reduction Nursing Interventions Carolyn Dimek, 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

2Q2017

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

5(Including 2 that did not meet definition)

Yes: 3No: 0N/A: 2

Yes: 5No: 0N/A: 0

Yes: 2No: 0N/A: 0

Yes: 3No: 0N/A: 2

Overall Compliance 100% 100% 100% 100% 100%

Data Analysis: There were 20 falls in the 1st Quarter of FY2017 with an overall compliance of 87%, which was a 4% increase from 4th quarter FY2016. There were 5 falls including 2 which did not meet definition in the 2nd Quarter of FY2017 with an overall compliance of 100%; this is a 13% increase from 1st Quarter. The question, “Fall risk score of 6 or higher- Is problem 6.1 initiated (164 A & B)?” was removed from aggregation with November reporting; nursing staff documentation has met the 100% goal for 4 consecutive months. This question will be evaluated by spot-check in 6 months to evaluate and ensure consistent and reliable documentation compliance. The current reporting for this question reflects October data only.There were 2 falls in October, 3 falls in November- 2 of which did not meet the definition of a fall, and Zero falls in December.

Action Plan: Auditing Nurse Supervisor provides education to staff during auditing process. Nursing administration will continue to follow up and audit all falls.

JOINT COMMISSION

JOINT COMMISSION

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 Carolyn Dimek, 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., McLean. 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., McLean. 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.

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 87 116

Number of patients with pain reported on Form 838

29 65 51 65

Number of reassessments completed

11 47 40 47

Number of reassessments reported within clinically appropriate timeframe(1-2 hours after oral medication and within 1 hour of intramuscular injection)

11 47 40 47

Compliance with reassessment 38% 72% 78% 72%

Compliance with reassessment timeframe

38% 72% 78% 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 and quarterly calculation. Audits were initiated in January 2013, January and February 2013 comprise the baseline data of 38%. 1st Quarter FY2017 showed a 5% decrease from previous quarter with 72%, a 34% increase

JOINT COMMISSION

from baseline. 2nd Quarter FY2017 shoes an increased compliance for both reassessment and reassessment timeframe with 78% compliance, 6% above 1st Quarter and 40% greater than baseline.

Action Plan: Nursing remains below the goal of 90% compliance this quarter. Nursing Administration continues to address this issue and will reinforce with the Clinical Nurse Managers to ensure that pain reassessments 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 that are not completing these assessments. Nursing administration is collaborating with clinical nursing staff to develop improved methods for reassessment documentation.

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 84 190

Number of audits having 2 shift assessments completed that assesses for the presence and intensity of pain within 24 hours

12 61 80 141

Overall Compliance 33% 58% 95% 74%

Data Analysis: The procedure for Pain Audit Shift Assessment was updated to include a change in form; patient pain assessments are completed once daily. Documentation of patient pain at least every 24 hours is acceptable practice and meets regulations. The 2nd Quarter measurements are comprised of November and December as October auditing was deferred during the revision process. Audits were initiated in January 2013, January and February 2013 comprise the baseline data of 33%. 1st Quarter FY2017 showed an overall compliance of 58%, a 14% decrease from previous quarter and 25% increase from baseline. 2nd Quarter FY2017 shows an overall compliance of 95%, a 5% increase over goal of 90%. This is a 37% increase from 1 st

Quarter’s 58% and a significant 62% above baseline.

October saw a change in management for the Nursing Department. The Performance Improvement indicators have been reviewed and revisions were made to the twice daily assessment of pain which was previously measured daily. This went into effect in October. Revisions were completed because the standard does not indicate the timeframes necessary for completion.

JOINT COMMISSION

Action Plan: Nursing exceeded the 90% goal this 2nd Quarter. Nursing Administration continues to monitor and audit to ensure procedure is being followed and that pain is being assessed at least every 12 hours for every patient. Clinical Nurse Managers will address documentation compliance with staff members that do not document these assessments.

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


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.


Each department determines unique opportunities and methods to address the hospital goals.

The Quarterly Report consists of the following:

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


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%

100% 100% 100% 100% 100%

Actual 93% 93% 93%

Data Analysis: The data indicates that we fell short of our goal of 100% certification by 7%.

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 and untrained newer employees.


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%18/18

100%33/33

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 2Q2017, 18 ceiling checks were performed. Of the 18 checks performed, all 18 were in compliance with life safety standards; therefore the overall compliance rate for the quarter is 100%.

Action Plan: None needed at this time.


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%25/25

100%57/57

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%25/25

100%57/57

Summary of patient’s psychosocial needs as appropriate to the patients *

94%30/32

92%23/25

93%53/57

Psychiatric Evaluation in patient’s record w/in 24 hrs. of admission

100%32/32

100%25/25

100%57/57

Psychiatric Evaluation authenticated within 60 hours of admission

84%27/32

92%23/25

88%50/57

Physician (TO/VO w/in 72 hrs.) 91%162/179

88%142/161

89%304/340

Evidence of appropriate informed consent

93%26/28

4 Declined

100%25/25

96%51/53

4 Declined

Clinical observations including the results of therapy.

100%32/32

100%25/25

100%57/57

Nursing discharge Progress Note with time of discharge departure

100%32/32

96%24/25

98%56/57

Consultation reports, when applicable100%10/1022 N/A

100%9/9

16 N/A

100%19/19

38 N/A

Advance Directive Status on admission and SW follow up after

94%30/32

96%24/25

95%54/57


Notice of Privacy 100%32/32

100%25/25

100%57/57

Chart Completion w/in 30 days of discharge date/discharge summary completed within 30 days

97%31/32

100%25/25

98%56/57

Discharge Packet sent to follow up provider within 5 days of discharge.

100%32/32

84%21/25

93%53/57

*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.


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 14 23

# of Staff Incidents 7 13 20

Data Analysis: In the 2Q2017, DDPC had 14 staff injuries and13 staff incidents; 19 were patient related, 1 patient assist, 1 fall/slip/trip, and1 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.


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% 13% 14%

# Vacancies

Posted14 8 8 8

# Vacancies

Filled Within 45

Days

6 3 3 3

% Posted & Filled

Within 45 Days

40% 38% 38% 38%

Data Analysis: This is new data collection in an effort to reduce extended time periods of vacant positions

Action Plan: Increase percentage rate of filled quarterly posted vacancies within 45 days of posting.


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 98

# Completed on Time

17 10 9 19

% Completed on Time

38% 20% 18% 19%

Data Analysis: The FY 2016 average percentage of performance evaluations submitted by the due date was at 38%; the 2QFY17 is at 18%, a 2% decrease from 1QFY2017 and 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. Reminders are sent by Human Resources to supervisors that employee evaluations are due two weeks prior to the due date and also additional reminders every two weeks until they are received.


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 0 HAI 1 HAI

Data Analysis: There was 0 hospital acquired infections for 2nd quarter FY2017, and 1 hospital acquired infection for 1sth quarter FY2017.

Action Plan: Continue to Monitor

FY

2014-2017 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 0 0URI 0 0 0 0 0 0 0 0 0 0LRI 0 0 1 0 0 0 0 0 0 0Skin 0 0 0 0 0 0 0 1 0 0Totals 0 0 0 0 0 0 0 1 0 0Infection Rate 0 0 0.26 0 0 0 0 0.28 0 0

H. A. Infections FY 2015 FY 2016 FY 20171st Quarter H.A.I. Rate 0 0 12nd Quarter H.A.I. Rate 0 0 03rd Quarter H.A.I. Rate 0 14th Quarter H.A.I. Rate 0 0Average H.A. Infection Rate 0 0.25


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=39873rd 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



Target:D1 90%

Quarterly response rate

“agree/strongly agree” for D1 &

D2 is set at 90%

2012: D1 response rate: 80%

86% 45% 66%

Target:D2 90%

2012: D2 response rate: 80%

86% 45% 66%

Data Analysis: Second Quarter FY2017 response rate for question D1 was 45%, a decrease of 48% from the previous quarter. 2nd Quarter FY2017 response rate for question D2 was 45%, a decrease of 48% from the previous quarter.

Action Plan: For FY2017, the goal has been increased to 90% compliance rate. IC RN will increase presence on the units, offering education to patients and ensuring that Purell is being offered/encouraged at meal times.


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% 90% 92%

Hamlin:87% 87% 93% 90%

Chamberlain: 93% 93% 87% 90%

Data Analysis: In the 2Q2017, Knox’s compliance rate was 90%, a decrease of 3% from the previous quarter; Hamlin’s compliance rate was 93%, an increase of 7% from the previous quarter; and Chamberlain’s compliance rate was 87%, a decrease of 6% from the previous quarter.

Action Plan: Continue to monitor HCW hand hygiene compliance per CDC guidelines.


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% 70%

Data Analysis: So far, FY2017 Data shows a 1% increase in compliance over last fiscal year.

Action Plan: Continue to educate staff and promote influenza vaccinations.

Comments: DDPC is currently hosting its annual Flu Clinic for 2016-2017.


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

Restraints

Baseline

(March 2015)

1Q 2Q 3Q 4Q YTD 201

72017 2017 2017

2017

Total Restraints 12 39 53 92

Is order complete? N/A 89% 100% 95%

On order, is the intervention stated in behavioral terms?

100% 87% 98% 93%

100%Does the time of the orders match interventions and times on Nursing forms?

N/A 94% 96% 95%

Is Medical Staff Seclusion and Restraint Progress Note complete (both sides)?

100% 65% 98% 82%

Is the time of the 1 hour face to face within an hour of the event? 100% 100

% 91% 96%

If PA, did PA consult with attending? 100% 81% 87% 84%Are the details of the event similar on all forms? 100% 93% 100

% 97%

Did the medical provider participate in the Seclusion and Restraint treatment plan review?

N/A 100% 94% 97%


Data Analysis: There were 39 restraints in the 1st quarter FY2017 with an overall compliance of 87%. 2nd Quarter shows an overall compliance of 96%; a 9% increase from previous quarter and


4% below baseline of 100%. As of 2nd Quarter, no elements of measurement have met the 100% goal for four consecutive months.

Goal 100% Compliance with Medical Staff Documentation

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.


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

Seclusions

Baseline

(March 2015)

1Q 2Q 3Q 4QYTD 20172017 2017 201

7201

7Total Seclusions 7 12 27 39

Is order complete? N/A 72% 100% 86%

On order, is the intervention stated in behavioral terms? 92% 56% 97% 77%

100%Does the time of the orders match interventions and times on Nursing forms?

N/A 100% 93% 97%

Is Medical Staff Seclusion and Restraint Progress Note complete (both sides)?

100% 44% 100% 72%

Is the time of the 1 hour face to face within an hour of the event? 100% 100

% 94% 97%

If PA, did PA consult with attending? 92% 100

% 83% 92%

Are the details of the event similar on all forms? 100% 100

%100%

100%

Did the medical provider participate in the Seclusion and Restraint treatment plan review?

N/A 100% 92% 96%



Data Analysis: There were 12 seclusion events in the 1st quarter FY2017 with an overall compliance of 84%. 2nd Quarter shows an increase in seclusion events to 27, with a significant increase in overall compliance to 95%; 11% above 1st Quarter and 1% below baseline. Medical Staff has met the goal for three data elements of measurement by meeting the 100% goal for 4 consecutive months. Questions “Is order complete” “Is Medical Staff Seclusion and Restraint Progress Note complete (both sides)?” and “Are the details of the event similar on all forms?” will be removed from aggregation and will be evaluated by spot check in 6 months to evaluate and ensure consistent and reliable documentation compliance.


Goal: 100% Compliance with Medical Staff Documentation

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. CMS 482.23 (c) Medications Drugs must be administered in response to an order from a practitioner, or on the basis of a standing order which is appropriately authenticated subsequently by a practitioner. In accordance with standard practice, all practitioner orders for the administration of drugs and biologicals must include at least the following:• Name of the patient;• Age and weight of the patients, or other dose calculation requirements, when applicable;• Date and time of the order;• Drug name;• Dose, frequency, and route;• Exact strength or concentration, when applicable;• Quantity and/or duration, when applicable;• Specific instructions for use, when applicable; and• Name of the prescriber.


Methodology: (Medical Staff Performance Improvement with Medical Records providing data). The Medical Director will review data provided by Medical Record monthly for compliance with all elements of a medication order. 10 to 15 medication orders per unit will be reviewed monthly by unit clerks for compliance with the elements of a medication order using and audit tool with a check of box of “yes” or “no”. The denominator will be all orders within the audit month. The numerator will be the elements of the order that are within compliance.

Goal: The goal is to have a combined compliance score of 100% with each element of a medication order for 4 consecutive months. The threshold is set at 90%. The results of the audits will be reported to the IPEC committee quarterly and the Advisory board.


Data Elements Baseline 4Q2016 1Q2017 2Q2017 3Q2017 4Q2017 Total

Compliance# of Medication orders reviewed 245 258 238 496

Medication order sheet has patient name, DOB and hospital number ID (2 patient identifiers)?

100% 100% 100% 100%

Date and time of the order 99% 99% 100% 99%Medication name 99% 100% 100% 100%Medication dose 96% 97% 99% 97%Route of administration 94% 97% 97% 96%Frequency of administration and/or dosing interval

92% 98% 99% 96%

Indication for use 90% 96% 98% 95%Authorized prescribers signature and credentials 97% 98% 99% 98%

Telephone orders completed, signed, dated and timed w/in 72 hr.

97% 100% 98% 98%



Data Analysis: “Medication order sheet has patient name, DOB and hospital number ID (2 patient identifiers),” “Medication name,” and “Route of administration” remain unchanged in percentages from previous quarter. “Date and time of the order,” “Medication dose,” “Frequency of administration and/or dosing interval,” “Indication for use,” and “Authorized prescribers signature and credentials” all increased this quarter by 1-2%. “Telephone orders completed, signed, dated and timed w/in 72 hr.” was the only decreasing element this quarter compared to last with a decrease of 2%. Overall compliance increased by 1% to 99% from 98% for 1st Quarter and increased 6% from baseline.

This 2nd Quarter of Fiscal Year 2017 brings noteworthy progress with 3 elements being removed from monthly reporting through November, and another being removed in December. These 4 elements: “Medication order sheet has patient name, DOB, and hospital ID (2 patient identifiers),” “Medication name,” “Telephone orders completed with physician signature, date and time within 72 hours,” and “Date and time of the order” have been removed from aggregation for having met the 100% goal for 4 consecutive months. Each


element will be evaluated by spot-check in 6 months to evaluate and ensure consistent and reliable documentation compliance Action Plan: Information will be disseminated monthly to Medical Staff. The Clinical Director will review and address compliance issues with Medical Staff.


Nursing Carolyn Dimek, 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

3Q201

7

4Q201

7YTD

100%Compliance

# of Events 35 39 53 391. Each order obtained within 15 minutes of the intervention?

83% 96% 100% 96%

4. Is Form 408 Nursing Seclusion/Restraint Progress Note complete?

95% 83% 95% 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% 96% 94%

9. Are details of event similar on all forms without discrepancies 408, 409, and Order sheets?

97% 93% 100% 93%

10. Is Form 470 Nursing Assessment Protocol for Seclusion and Restraint completed?

96% 100% 100% 100%

15. Were debriefings DB1 & DB2 completed at

99% 89% 96% 89%


appropriate times?16. Is patient debriefing in the chart? 89% 93% 94% 93%


e4Q2016

1Q2017

2Q2017

3Q201

7

4Q201

7YTD

100%Compliance

19. Was Form 470 TX Focused Treatment Plan Review completed within 24 hours?

88% 91% 92% 91%


Data Analysis: Baseline data compiled August 2015 with updates to Seclusion and Restraint procedure, forms, and audit tool since that time. The 1st quarter of FY2017 showed a compliance rate of 92%, a 1% decrease from 4th quarter FY2016 and a 4% increase from baseline. 4 Elements increased and 4 elements decreased with negligible statistical impact. 2 nd

Quarter shows an overall compliance of 94%, a 2% increase from 1 st Quarter and 6% above baseline. 7 elements increased with none decreasing.

There were 53 restraint events this quarter with totals of: Knox 12, Hamlin 13, and Chamberlain 28. There were 4 mechanical restraint events; the remaining events were manual holds. Numerous restraint events can be contributed to same-patient manual holds over the course of the quarter. Unit totals for 2nd Quarter overall compliance are: Knox- 96%, a 2% increase from 1st Quarter’s 94%, Hamlin-93%, a 1% decrease from 1st Quarter’s 94%, and Chamberlain- 96%, a 7% increase from 1st Quarter’s 89%.

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. Nursing staff met the goal for 2data elements this quarter; these will no longer be included in reporting: The question (#10), “Is Form # 470 Nursing Assessment Protocol for Seclusion and Restraint completed?” was removed from aggregation with its last reporting in October; nursing documentation met the 100% goal for 4 consecutive months. This question will be evaluated by spot-check in 6 months to evaluate and ensure consistent and reliable documentation compliance. The question (#1), “Each order obtained within 15 minutes of the intervention?” was removed from aggregate reporting for December; nursing documentation met the 100% goal for 4 consecutive months with November reporting. This question will be evaluated by spot-check in 6 months to evaluate and ensure consistent and reliable documentation compliance.


Action Plan: Nursing staff shows improvement in documentation, but remains below goal. Nursing 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.


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


e4Q2016

1Q2017

2Q2017

3Q2017

4Q2017 YTD

100% Compliance

# of Events 13 10 27 371. Each order obtained within 15 minutes of the intervention?

91% 89% 100% 95%

4. Is form #408 Nursing Seclusion/Restraint Progress Note complete?

82% 89% 100% 95%

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%

9. Are details of event similar on all forms without discrepancies #408, #409, and Order sheets?

100% 100% 100% 100%

10. Is Form # 470 Nursing Assessment Protocol for Seclusion and Restraint completed?

88% 100% 100% 100%

11. On Form # 407RN 2 Hour Seclusion and Restraint Breaks 2 hour breaks are completed at

84% 100% 97% 99%


appropriate intervals and signed by RN?

Results


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% 86% 88%

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% 96% 84%

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% 82% 75%

15. Were debriefings DB1 & DB2 completed at appropriate times?

100% 83% 97% 90%

16. Is patient debriefing in the chart? 75% 100% 95% 98%

19. Was Form # 470 TX Focused Treatment Plan Review completed within 24 hours?

86% 83% 97% 90%



Data Analysis: Baseline data compiled August 2015 with updates to Seclusion and Restraint procedure, forms, and audit tool since that time. The 1st quarter of FY2017 showed a compliance rate of 89%, a 4% increase from 4th quarter FY2016/baseline. 6 elements increased and 4 elements decreased and 2 elements stayed the same. 2nd Quarter shows an overall compliance of 95%, a 6% increase from 1st Quarter and 10% above baseline. 6 elements increased and 3 decreased.

There were 27 seclusion events this quarter with totals of: Knox 8, Hamlin 8, and Chamberlain 11. There were 2 open-door seclusions and the remaining 25 events were locked-door seclusions. Numerous seclusion events can be contributed to same-patient events over the course of the quarter. Unit totals for 2nd Quarter overall compliance are: Knox- 93%, a 3% decrease from 1st Quarter’s 96%, Hamlin-94%, a 1% decrease from 1st Quarter’s 93%, and Chamberlain- 96%, matching 1st Quarter’s compliance.

Nursing staff met the 100% goal for 4 consecutive months for 5 data elements this quarter; these will no longer be included in reporting: Questions (#1) “Each order obtained within 15 minutes of the intervention?” (#4) “Is form #408 Nursing Seclusion/Restraint Progress Note complete?” (#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?” (#9) Are details of event similar on all forms without discrepancies #408, #409, and Order sheets?” and (#10) “Is Form # 470 Nursing Assessment Protocol for Seclusion and Restraint completed?” These questions will be evaluated by spot-check in 6 months to evaluate and ensure consistent and reliable documentation compliance.


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. Nursing documentation will be extracted and separated from Medical Staff documentation. 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.

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

2Q2017Patient Unit# of Coercive Events Knox

20?Hamlin

21?

Chamberlain

39?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 0/8 0/3 1/14


attend debriefing? attended attended attendedData Analysis: 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.

IV. Measure Name: Form 222B will be completed per procedure. Measure Description: Special Observations of DDPC patients are recorded on form 222B as part of the permanent medical record. “Special Observations (SO) is a method of preventing acutely disturbed psychiatric inpatients from harming themselves or others. It involves assigning an identified person to the care of the ‘at-risk’ patient for a certain period of time, above the minimum general level of observation required for all inpatients.” SO may be intermittent or constant and may last between a few hours to several weeks; the most frequent reason for SO is prevention of self-harm, but is also used for other patient safety issues [Stewart, D., & Bowers, L. (2012). Under the gaze of staff: Special observation as surveillance. Perspectives In Psychiatric Care, 48(1), 2-9. doi:10.1111/j.1744-6163.2010.00299.x].In accordance with Dorothea Dix Psychiatric Center procedure, all 222B forms will include the following documentation components:• Patient label• Observation level (frequency)• Reason for observation• Date of form• 24 hour Charge Nurse coverage• Every charge nurse will sign, date, & time in designated area on form• No incomplete initial or location boxes Type of Measure: Performance Improvement

Methodology: Nursing Performance Improvement will collect, review, formulate, and report data from inpatient units for compliance with all elements of form 222B completion. Every 222B patient observation form will be reviewed monthly for compliance using audit tool with


boxes for numbers of total expected and total correct 222B forms. The Pass Status Sheet is compared with each unit’s supplied 222B forms to ensure full collection. The denominator will be all expected 222B forms; the numerator will be the number of all 222B forms completed correctly within the month. Baseline data established in October 2016 (see chart).

The goal is to have a combined compliance score of 90% for 4 consecutive months. The results of the audits will be reported to the IPEC committee quarterly and the Advisory board.

Baseline Oct 2016 2Q2017Data Elements K1 K2 K3 Combined

Compliance K1 K2 K3 Combined Compliance

Total 222B Forms 54 170 55 279 159 173 64 396

Total Correct 222B Forms 42 161 42 245 147 166 35 348

Overall Compliance 78% 95% 76% 88% 92% 96% 55% 88%

Data Analysis: November was the first official reporting of this measure; this first quarterly report comprises combined results from November and December 2016. The overall compliance for all three units for 2nd Quarter FY2017 is 88%, equal to baseline.

K1- Compliance is 92% this exceeds goal by 2% and is a 14% increase above unit baseline. K2- Compliance is 96% this exceeds goal and is a 1% increase above unit baseline.K3- Compliance is 55% this does not meet goal and is a 21% decrease below unit baseline.

Action Plan: The combined overall compliance is below goal; Nursing Administration will continue to address deficiencies in documentation with Clinical Nurse Managers and provide information related to each deficiency for unit follow up.


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%

Total # of Reports Due? 8 4 11 15# of Institutional Reports Due? 3 4 2 6

Institutional Report submitted within 10 days of notice of hearing being received by DDPC?

33% 100% 100% 100%

# of Annual Reports Due 5 0 9 9Annual Report submitted by December 31, 2015? 80% N/A 100% 100%



Data Analysis: The data element “Institutional Report Submitted within 10 days of notice of hearing being received by DDPC was at 100% for 2Q2017, which continues to meet our goal of 100% compliance. Please note that there is also a correction for 1Q2017 as this data element was reported as 2 reports due when there were actually 4; however, the compliance remained at 100%. The data element “Annual Report Submitted by December 31, 2016” was also at 100% which is up from 80% in FY2016. The overall compliance remained at 100% from 1Q to 2Q 2017.

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 and this and other necessary information must be in the patient’s medical record. In order for necessary information to be used it must be promptly filed and available in the medical record so that health care staff involved in the patient’s care can access/retrieve this information in order to monitor the patient’s condition and provide appropriate treatment and client services.

Results

Target Data elements BaselineFY2016

1Q2017

2Q2017

3Q 2017

4Q2017 YTD

90%

# of Notes 778 173 312 485Psychiatric notes entered within 72 hours? 83% 89% 82% 86%

Nursing notes entered within 72 hours? 98% 100% 98% 99%

Social Work notes entered within 72 hours? 88% 97% 100% 99%

Psychology notes entered within 72 hours? 78% 83% 73% 78%



Data Analysis: Data elements “Psychiatric Notes Entered within 72 hours”, “Nursing Notes Entered within 72 hours” and “Psychology Notes Entered within 72 hours” all decreased in compliance from 1 st Q FY 2017 to 2nd Q FY 2017 although nursing notes only decreased slightly from 100% to 98%. “Social Work notes entered within 72 hours” increased slightly from 97% to 100%. Overall compliance increased slightly from 94% to 96% and still remains above the 90% compliance rate. Please note that the overall number of notes nearly doubled this quarter due to the admission of additional patients and increased need of services over the past 3 months. Social work was able to maintain 100% compliance with 192 notes being entered for the quarter which accounted for 62% of all outpatient notes. The most significant drop in compliance was in Psychology notes which decreased from 83% to 73%.

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. Concerns are forwarded to the appropriate supervisor so that they can be addressed individually as part of ongoing competency evaluations.


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 YTD

100%

# of Assessments 8 5 3 8

Psychiatric assessment complete and entered within 30 days? 50% 100% 100% 100%

Nursing assessment complete and entered within 30 days? 88% 100% 100% 100%

Social Work assessment complete and entered within 30 days? 88% 100% 100% 100%



Data Analysis: There were 2 patients with initial assessments due and 1 patient with annual assessments due during 2ndQ FY 2017. Please note the patient with annual assessments due did not show for his appointment but his chart remains open at this time so all disciplines completed assessment updates noting this with the exception of nursing, as they cannot complete the assessment without the patient present. This is an increase from the baseline of 75% overall compliance during FY 2016.

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 through the 4th Q (due to the grouping of dates when patients were admitted there won’t be any more due until then) then this performance improvement measure can be discontinued and a new measure will be determined.


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 1246 2113

Data Analysis: The number of clinical interventions continues to hold steady and increase, largely due to the development of new monitoring programs instituted by the pharmacy staff. The pharmacy is now participating in monitoring all of the patients’ renal function, electrolyte levels, and metabolic parameters to identify areas for medication use optimization. The data collection and recording system continues to be enhanced, accounting for a further increase in the number of 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 and medical providers have instituted a comprehensive metabolic monitoring program, so the number of interventions is only expected to increase.


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 orders1010

100% 100% 100% 100% 100%Actual 100% 100% 100%Target Did RPh need to

resolve PE orders9 1 0% 0% 0% 0% 0% 1 simple

clarificationActual 50% 10% 30%Target Were PE meds

Clearly identified when clarified

0 10 100% 100% 100% 100% 100%Actual 100% 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% 100%

Target Was a one-time PE intervention specified as an Emergency Med?

0 0 100% 100% 100% 100% 100%Actual 100% 100% 100%

Target Did any Emergency Med not end in 72 hours?

0 0 0 0 0 0 0Actual 0 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 N/A

Data Analysis: There were ten psychiatric emergencies declared during the second quarter. One of them required a simple clarification, but the rest of the orders were complete and did not require pharmacist intervention.

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.


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 12 42

7am-3pm 5 17 7 243-11pm 5 10 5 15

11pm-7am 2 3 0 3

Data Analysis: As expected, most variances occur during the day shift as this is when most medications are administered and when patients are typically the most active.

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 continue to work together to address any concerns so that issues can be addressed before they reach the patient. The medication variance team is also working on revising the reporting process so that each variance can be more readily addressed with all of the appropriate individuals and departments to prevent similar circumstances from reoccurring. .

Comments: The staff continues to work to avoid variances whenever possible and continues to report them promptly as necessary.


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 12 51

Two forms of patient ID not used 1 3 4Inaccurate check of MARNot Yellowed on MAR 1 1MD order issues 1 1MAR print out wrong 1 4New order overlooked 2 2 4New order 1 2 3High Alert Med 2 2Pyxis loading error 1 1Med Overlooked 8 5 4 9Distractions 2 2 2Dispensing errorProcedure not followed 2 18 12 30Unclear order 1 1Transcription 4 1 5*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 second quarter the most common contributing factor to medication variances was that the appropriate procedure was not accurately followed. This quarter the majority of the variances were due omissions, which resulted when a particular medication was overlooked.

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.

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 1 4Extra Dose 1 2 2Wrong Time 3 2 5Wrong Drug 2 2Wrong FormFrequencyOmission 7 10 5 15Wrong Patient 1 3 4Schedule 1 1Expired Drug 1Procedure Not Followed 1 8 8Drug Not Loaded 1 1DispensingTotal 11 30 12 42

Methodology: The staff member that discovers the variances 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 committee meetings, the staff pharmacist compiles the variances and reports on them to the rest of the committee for discussion.

Data Analysis, Action Plan, and Comments: DDPC does a very good job of addressing variances promptly. DDPC will continue in its efforts to decrease the number of variances and provide re-education to the personnel involved as they arise. The second quarter saw an overall decrease in the number of medication variances and the facility will work to continue to decrease the number of errors.


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/

month6/

month7.65/

monthNumber of

CS lost 0 0 0 0

Data Analysis: There were, on average, 6 controlled substance discrepancies per month for the second 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 miscounts.

Action Plan: Pharmacy will continue to increase visibility and availability to the units to provide education regarding how CS discrepancies occur and how they can be avoided.

Comments: We will continue to strive for a 0% loss of controlled substances.

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 $157.16/5 Rxs

$26.83/17 Rxs

$183.99/22 Rxs

Data Analysis: The outpatient prescriptions have occurred this quarter when the patients are being discharged or sent on leave to jail. Discharge prescription costs for the second quarter were excellent, totally just $26.83 for 17 prescriptions.


Action Plan: Great strides have been made in reducing the cost of discharge medications. This task primarily falls to the 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 and a current focus is to reduce the number of medications that are not going to be used at the jails. Comments: DDPC continues to be successful with minimizing the costs of discharge medications. This continues to be 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% 100%

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 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: Pharmacy continues to strive for 100% complete medication room and storage area audits and will continue utilizing the effective current processes to maintain efficiency.

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 direct recognition of deficiencies. Since the revised process has been in place there has been 100% completion of all inspections.

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


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.

Data Analysis: For 2Q2017 the number of invalid orders decreased by approximately 40% from the previous quarter. This is reflective of the increased efforts on the part of the prescribers and coordination with pharmacy to work towards the goal of zero incomplete orders. The most common invalidating factors are 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 current trends and challenges that have been identified. The pharmacy department 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. Once the conversation has occurred, the need to track incomplete orders will become obsolete.

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

Results

Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD

TargetPolyantipsychotic

Therapy TBD

TBD TBD TBD TBD TBD

Actual 33.6% 21% 27.3%

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. This data represents the first step in developing that formalized process. 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 quarter, 21% 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


Target Complete/ Up-to-date Metabolic

Parameters

TBD50% 65% 70% 75% 75%

Actual 69.9% 85.7% 77.8%

Data Analysis: The pharmacy completes data collection of metabolic monitoring parameters for all hospital patients on at least a monthly basis. 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 program began at DDPC in July of 2016 an initial goal of having at least 50% of patients with complete monitoring parameters was determined. Pharmacy worked closely with the medical providers to surpass the first goal with 69.9%, and continued to improve during the second quarter with 85.7% of patients having complete and up-to-date laboratory results. When patients who refused monitoring tests are accounted for this figure increases to 94%.

Action Plan: We 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 assess their metabolic status, explaining why the goal is not 100%. The pharmacy and the medical providers are both excitedly looking forward to the successful 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, 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.

XII. Measure Name: Turn-Around Time Audit

Measure 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: 10/1/2016 – 10/31/2016Turn Around Time Audit, daily afterhours activity (4pm-8am)

Total Orders 97Order Status

Routine 78 80.4%Stat 19 19.6%

Turn Around TimeAverage turn around (minutes) 36.27Average processing time (minutes) 7.81

Time period: 11/1/2016 – 11/30/2016Turn Around Time Audit, daily afterhours activity (4pm-8am)

Total Orders 74Order Status

Routine 68 91.9%Stat 6 8.1%


Time period: 12/1/2016 – 12/31/2016


Turn Around Time Audit, daily afterhours activity (4pm-8am)Total orders 60

Order StatusRoutine 59 98.3%Stat 1 1.7%


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.


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.

Methodology: All 30 day readmissions to include admissions within the Progressive Treatment Program (PTP) will be reviewed monthly by using a modified root cause analysis tool. The denominator will be all 30 day readmissions and the numerator will be all patients with a completed modified root cause analysis within 45 days of readmission.

Baseline Data: To be determined

GOAL: The goal is to have 100% compliance with the completion of a 45 day modified root cause analysis for all 30 day readmissions.

Month Pt FD # Date of Readmission

Date of Completed Modified RCA

% Compliance

October 2016

N/A N/A N/A N/A

November 2016

N/A N/A N/A N/A

December2016

N/A N/A N/A N/A

Data Analysis: There were no 30 Day Readmissions in the 2nd quarter of FY 2017.

Plan of Action: Not applicable


Results

Target Data elements Baseline4Q2016

1Q2017

2Q2017

3Q2017

4Q2017 YTD

Readmissions within 30 days of discharge 2 3 0 3

Progressive Treatment Plan (PTP)readmissions within 30 days 1 2 0 2

45 day root cause analyses due within the quarter 2 2 0 2

100%

Compliance with completion of a 45 day modified root cause analysis for all 30 day readmissions

100% 100% N/A 100%


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 22 35Unit Staff compliant with addressing grievance? 89% 92% 55% 74%

Unit Staff completed form correctly (boxes checked, dated/timed, all signatures completed, Nurse Supervisor notified)?

63% 38% 64% 51%

*Nursing Supervisor compliant with addressing grievance within 4 hours?

86% 92% 91% 92%

Nurse Supervisor completed form correctly (boxes checked, dated/timed, all signatures completed, forwarded to Social Worker)?

61% 31% 77% 54%

*Social Worker compliant with addressing grievance within 5 days or within 5 more days if extension is requested?

100% 100% 82% 91%

*Overall Compliance of Nursing Supervisor and Social Worker addressing grievance

93% 96% 86% 72%


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 decreased in compliance from 96% to 86% from 1 st Q FY 2017 to 2nd Q FY 2017. The data element “Nurse Supervisor compliant with addressing grievance within 4 hours” decreased from 92% to 91% and “Social Worker compliant with addressing grievance within 5 days or within 5 more days if extension is required” decreased from 100% to 82% due to social worker being out of the office. There was a marked decrease of unit staff addressing the grievance as this decreased from 92% to 55%, this may be due to new staff of staff not fully understanding the procedure of speaking with the patient about their grievance before calling the nurse supervisor or due to patients requesting to bypass staff. The data element “Nurse Supervisor completed form correctly” increased from 31% to 77% which was a significant increase. It should also be noted that December saw a significant increase in grievances, going from 5 in October and 3 in November to 14 in December.


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 (needs to be reviewed by the patient advocate as well as administration), as well as separate forms for complaints and grievances which will address some of the challenges of filling out the forms correctly. The decrease of compliance was directly affected by social worker being out sick for several days and nurse supervisor compliance was also down which may be attributed to different staff being pulled in for coverage of that role in the evenings. The Director of Nursing has been advised of the concerns and has been provided with grievance examples where forms are not completed correctly and she has provided education to her staff as well.


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 Improvement

Methodology: 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 staff education year end in 2Q of each fiscal year.

Data Analysis: The graph table below for 2Q2017 reflects year end percentages for the Staff Education year ending 12/31/16.


Learning Packets 1Q2017 2Q2017 3Q2017 4Q2017AMD 45% 91%BOUND 99%BTUCS 99%CAUTI's 60% 96%CNA 100%COAG 56% 98%CPR 98%CUSHION 89%Diversity 81% 98%DM Risk 82% 98%DYINGPT 79% 98%EBOLA 99%EOC 94%


ETHICS 100%EVAC CHAIR 81% 88%FALLS 100%GLUCOCE 55% 98%HOCOMM 86% 95%IC-ILI 99%ILP 99%INFCON 99%LIFESP 99%MANDT/SRST 100%MDRO 99%MEDSFYQ 98%NPSG-L 95%NPSG-MH 100%PAIN RN/MD 99%PI/SE Q 99%RN EXAM 100%S/R LP 97%

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 prior to the staff education year end to address their staff that are out of compliance, and will alert the Superintendent of employees out of compliance.

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.


Target Number of 0% 0% 0% 30% 60% 100%


EmployeesActual 0% 0% 0%

Data Analysis: No employees were scheduled for First Aid in the 2nd 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 January 1, 2017.


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 OT Recreation VocationalOctober 39 49 43 53 53November 37 48 31 57 50December 41 49 37 59 562Q2017 Avg. 39 49 37 56 53


A. Measure Name: Direct Patient Contact - Occupational Therapy


Target Percent of time spent

in direct patient contact.

36% March2015

50% 50% 50% 50% 50%

Actual 48% 37% 43%

B. Measure Name: Direct Patient Contact - Therapeutic Recreation




53%March 2015

50% 50% 50% 50% 50%

Actual 55% 56% 56%

C. Measure Name: Direct Patient Contact - Clinical Services




35%March 2015

50% 50% 50% 50% 50%

Actual 41% 39% 40%


D. Measure Name: Direct Patient Contact- Ancillary Services (Dietician, Chaplain, Peer Support)




31%March 2015

50% 50% 50% 50% 50%

Actual 55% 49% 52%

E. Measure Name: Direct Patient Contact- Vocational Services (comprised of occupational therapy and recreation staff in previous quarter)




53%2017

- 50% 50% 50% 50%

Actual - 53%(Baseline) 53%

Data Analysis: A dip in provider direct care statistics was expected given the planning and research required for therapeutic services organization changes that occurred mid-November, 2016. Providers are now more dependent on physician referral and must work with a smaller, targeted population that may be difficult to engage. Hospital-wide programming expanded mid-November to include multi-disciplinary offerings seven days per week. Therapeutic recreation and vocational services have maintained greater than 50 percent for three consecutive months and will cease to be monitored as performance improvement measures and moved to quality assurance instead.

Action Plan: Request a weekly time study from providers achieving less than 45 percent direct patient contact for the quarter. A meeting with those providers will be scheduled to discuss barriers to providing treatment. Continue to monitor caseload based on physician referral.


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


A. Therapeutic Recreation Evaluations Goal: All therapeutic recreation evaluations will be completed within seven days of referral. Numerator: Recreation evaluation requests completed within seven days of the

order date. Denominator: Total recreation evaluations received.

Results


TargetPercent of recreation

evaluations completed

within seven days of the order date.

28%

N/A 90% 90% 90% 90%

Actual N/A28%

(Baseline)

28%

B. Occupational Therapy Evaluations Goal: Occupational therapy evaluations to include; self-care, community participation, health and well-being, life skills development, self-regulation, physical rehabilitation orders will be completed within seven days of referral. Numerator: Occupational therapy evaluations (less ILS) completed within

seven days of the order. Denominator: Total occupational therapy evaluations (less ILS) received.


TargetPercent of OT

evaluations (less ILS) in the record within seven days of

referral.

41%

N/A 90% 90% 90% 90%

Actual N/A 41%(Baseline) 41%


C. Occupational Therapy: Evaluation of Placement Needs (ILS) Goal: ILS evaluations will be completed within ten days of referral.

Numerator: ILS evaluations completed within ten days of referral. Denominator: All ILS evaluations received.


Target Percent of ILS evaluations completed

within ten days of referral.

58%

N/A 90% 90% 90% 90%

Actual N/A 58%(Baseline) 58%

D. Substance Abuse Assessment Goal: Substance abuse assessment completed within seven calendar days of the referral. Numerator: Substance abuse assessments completed within seven days of

referral. Denominator: All substance abuse assessment referrals received

Results


TargetPercent of

substance abuse assessments in

the record within seven

days of referral.

50%May 2016

90% 90% 90% 90% 90%

Actual 100% 33% 67%


E. Psychology – Issue Specific Evaluation Goal: Psychological evaluations completed within 30 days of referral.

Numerator: Psychological evaluations completed within 30 days of referral. Denominator: All Psychological evaluations received.


TargetPercent of

psychological evaluations completed

within 30 days of referral.

0%May 2016

90% 90% 90% 90% 90%

Actual 0% 17% 9%

Data Analysis: Significant departmental changes contributed to poor timeliness of evaluation percentiles across all disciplines. Other factors detracting from timeliness of evaluations include: Nineteen service orders were received 11 or more days late from the unit, duplicate orders resulted in confusion in processing and six orders were received over four-day, holiday weekends resulting in a delay assigning to a provider. Additionally, providers initiated treatment on patients that had been re-admitted based on prior admission assessments resulted in confusion in processing.

Action Plan: To address orders being received late from the units nursing staff were provided education for the proper referral process. Therapeutic services staff have been reminded of the expectation for timely evaluations despite vacation, holiday, and sick leave. Staff have been made aware that a new assessment is required to guide treatment for each admission and/or referral. Therapeutic Services will continue to monitor and address individual performance issues.

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