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Post Discharge Readiness for Those Discharged -

Q4 2011 (N=40)

68.8%

7.8%

9.4%

14.1%

0-7 Days

8-30 Days

31-45 Days

45+ Days

Performance Improvement Report

FOURTH state fiscal quarter 2011

April, May, June 2011

Mary Louise McEwen, SUPERINTENDENT

July 22, 2011

Table of Contents

INTRODUCTION 1

ADMISSIONS 2

COMMUNITY FORENSIC ACT TEAM 4

CAPITOL COMMUNITY CLINIC 7

CLIENT SATISFACTION 11

COMPARATIVE STATISTICS 14

DIETARY 39

HARBOR TREATMENT MALL41

HEALTH INFORMATION MANAGEMENT 42

HOUSEKEEPING 44

HUMAN RESOURCES 46

INFECTION CONTROL 50

LIFE SAFETY 51

MEDICAL STAFF 54

NURSING 55

PEER SUPPORT 60

PHARMACY & THERAPEUTICS 62

PROGRAM SERVICES 64

REHABILITATION SERVICES 66

SECURITY & SAFETY67

SOCIAL WORK 68

STAFF DEVELOPMENT 72

CONSENT DECREE COMPLIANCE STANDARDS SUMMARY 73

INTRODUCTION

The various departments at Riverview Psychiatric Center continue to strive to meet or exceed the substantial compliance standards as outlined in the consent decree. In addition, each department conducts other performance improvement activities that are designed to enhance the process and environment of safety and care for residential and ACT clients in the Maine Adult Mental Health System. The overall goal of this endeavor is provide these services with an eye toward client recovery and organizational excellence while continuing to recognize the need to maintain a high degree of efficiency and fiscal responsibility.

There are some significant changes to this report in an attempt to clarify some of the information contained herein. The section on Comparative Statistics has been completely redesigned to make many of the charts more easily readable, especially for those with difficulty in color differentiation. In addition, the main graph that depicts the results of the facility in the various aspects being evaluated has been changed to exclude the data from the Dorothea Dix Psychiatric Center. This was done primarily to allow a more accurate comparison between the two facilities. Whereas the Riverview Psychiatric Center cares for a mix of forensic and civil clients, the Dorothea Dix Psychiatric Center client population is, for all intents and purposes, a civil population. To provide an accurate comparison of the results from the two facilities, the Dorothea Dix Psychiatric Center data is now depicted on a civil stratification chart for each of the aspects evaluated that also includes data on the civil population at Riverview Psychiatric Center.

The use of seclusion and restraint as a safety mechanism for clients and staff in the clinical setting remains a focus of risk and process improvement activities. Both the number and duration of client incidents managed with restraint and seclusion techniques is variable and often dependent upon client acuity and concerns for maintaining client safety. The duration of both seclusion and restraint remain the national mean as determined by the National Association of State Mental Health Program Directors Research Institute (NRI). For the same period, the average number of restraint and seclusion incidents over the past several quarters has been within one standard deviation of the national mean as determined by NRI. Efforts continue to further reduce the incidence of both restraint and seclusion while maintaining the safety of the client, the milieu and our staffs.

Ongoing efforts to modify analysis and treatment methods to respond to client agitation and escalation have produced some examples of success with individual clients. Efforts to widely adopt these proactive methods throughout the milieu are implemented on a case by case basis as trends are identified through an ongoing system of data collection and analysis.

Introduced last quarter, the section on Consent Decree Compliance continues to be developed. The elements of substantial compliance abstracted from this document are listed with an explanation of how current operations fulfill the standards described. Several of the compliance standards require specific evidence or documentation of compliance that in various stages of development. One of these evaluation methods includes an ongoing process for evaluating the appropriate application and management of seclusion and mechanical restraints. This tool has been implemented and ongoing reports regarding this measure have been included in this report. As this reporting mechanism is developed, it is expected that subsequent reports will address all of the standards of substantial compliance in a manner that demonstrates a good faith effort to maintain continual compliance with all of the elements of the Consent Decree and to maintain an environment and treatment methods that are both safe and therapeutic and focused on the recovery of the client.

(Back to Table of Contents)

ADMISSIONS

Figure CD-06

2011

Total

Client Admission Diagnoses

Qtr1

Qtr2

Qtr3

Qtr4

ADJUSTMENT DIS W MIXED DISTURBANCE OF EMOTIONS & CONDUCT

1

1

2

ADJUSTMENT DISORDER WITH DEPRESSED MOOD

1

2

1

4

ADJUSTMENT DISORDER WITH MIXED ANXIETY AND DEPRESSED MOOD

1

1

ADJUSTMENT REACTION NOS

1

1

2

ALCOH DEP NEC/NOS-REMISS

2

2

BIPOL I DIS, MOST RECENT EPIS (OR CURRENT) MANIC, UNSPEC

1

1

BIPOL I, MOST RECENT EPISODE (OR CURRENT) MIXED, UNSPECIFIED

1

1

BIPOL I, REC EPIS OR CURRENT MANIC, SEVERE, SPEC W PSYCH BEH

1

1

2

BIPOLAR DISORDER, UNSPECIFIED

10

11

11

11

43

CANNABIS ABUSE-IN REMISS

1

1

CONDUCT DISTURBANCE NOS

1

1

DELUSIONAL DISORDER

2

2

2

2

8

DEPRESS DISORDER-UNSPEC

1

1

DEPRESSIVE DISORDER NEC

5

7

4

5

21

DRUG ABUSE NEC-UNSPEC

1

1

DYSTHYMIC DISORDER

1

2

3

HEBEPHRENIA-CHRONIC

1

1

2

INTERMITT EXPLOSIVE DIS

1

1

NONPSYCHOT BRAIN SYN NOS

1

1

OPPOSITIONAL DEFIANT DISORDER

1

1

PARANOID SCHIZO-CHRONIC

4

5

7

6

22

PARANOID SCHIZO-UNSPEC

5

2

2

4

13

POSTTRAUMATIC STRESS DISORDER

2

3

4

4

13

PSYCHOSIS NOS

13

14

4

7

38

REC DEPR DISOR-PSYCHOTIC

2

2

4

RECURR DEPR DISORD-UNSP

1

1

2

SCHIZOAFFECTIVE DISORDER, UNSPECIFIED

14

13

13

21

61

SCHIZOPHRENIA NOS-CHR

4

2

1

6

13

SCHIZOPHRENIA NOS-UNSPEC

1

2

1

4

SCHIZOPHRENIFORM DISORDER, UNSPECIFIED

1

1

UNSPECIFIED EPISODIC MOOD DISORDER

3

5

3

3

14

Total Admissions

75

76

58

75

284

% Admitted with primary diagnosis of mental retardation, traumatic brain injury, dementia, substance abuse or dependence.

2.67%

2.67%

0

0

1.41%


ADMISSIONS

Figure CD-04

2011

Total

Client Legal Status on Admission

Qtr1

Qtr2

Qtr3

Qtr4

ICDCC

3

17

26

23

69

ICDCC-PTP

1

1

IC-PTP+M

1

1

ICRDCC

1

2

3

INVOL CRIM

19

20

29

30

98

INVOL-CIV

1

2

7

2

12

PCHDCC

1

2

3

PCHDCC+M

1

1

2

VOL

35

34

11

10

90

VOL-OTHER

1

1

1

2

5

ICDCC-M

3

3


COMMUNITY FORENSIC ACT TEAM

Aspect: Reduction of re-hospitalization for ACT Team clients

Indicators

Findings

Compliance

Threshold

Percentile

1. The ACT Team Director will review all client cases of re-hospitalization from the community for patterns and trends of the contributing factors leading to re-hospitalization each quarter. The following elements are considered during the review:

a. Length of stay in community

b. Type of residence (i.e.: group home, apartment, etc)

c. Geographic location of residence

d. Community support network

e. Client demographics (age, gender, financial)

f. Behavior pattern/mental status

g. Medication adherence

h. Level of communication with ACT Team

One PTP client was admitted this quarter, he was in the community less than 1 week in a group home.

100%

100%

2. ACT Team will work closely with inpatient treatment team to create and apply discharge plan incorporating additional supports determined by review noted in #1.

100%

100%

100%

Summary

1. The PTP client was re-admitted to RPC after de-stabilizing while living in a group home in Augusta. He had his medications administered by staff and there is reason to believe may have not swallowed them (mouth checks were not done). Upon his next discharge to the community, it would be beneficial to have mouth checks done to enhance this client’s ability to fully stabilize in residential treatment in the community.

2. The ACT Team has become more collaborative in treatment team meeting participation while clients are in the hospital, particularly regarding recommendations for goals of re-hospitalization.



Aspect: Institutional and Annual Reports

Indicators

Findings

Compliance

Threshold

Percentile

1. Institutional Reports will be completed, reviewed internally, and delivered to the court within 10 business days of notification of submitted petition.

4 of 7 on time

60%

95%

2. The assigned case manager will review the new court order with the client and document the meeting in a progress note or treatment team note.

4 new court orders, all reviewed.

100%

100%

3. Annual Reports (due Nov) to the commissioner for all out-patient Riverview ACT NCR clients are submitted annually

N/A

N/A

100%

Summary

1. Eight clients petitioned to have their cases heard on the 5/13/11 court date; one withdrew his petition so seven went to court. Four of seven had Institutional reports completed on time. The major factor influencing this poor outcome was the continued revision of the internal process for writing/filing reports. The process has been further improved to include essential reviewers and continued emphasis on deadlines triggered with the receipt of petitions.

2. ACT Team Leader delivers all new Court Orders to Case Managers upon receipt, who then reviews with both client and supported housing staff involved in compliance with order. This is documented in progress notes and/or reviewed in ISP treatment team.

3. Annual Reports were not due within this quarter.

Aspect: Substance Abuse and Addictive Behavior History

Indicators

Findings

Compliance

Threshold

Percentile

1. age of onset documented in Comprehensive Assessment

40/40

100%

95%

2. duration of behavior documented in C.A. and progress notes

39/40

90%

95%

3. pattern of behavior documented in C.A. and progress notes

39/40

90%

95%

Summary

The Co-Occurring Specialist has begun to review all urinalyses for illicit drug/alcohol use. We believe this will streamline the process of responding to the client with the information and will identify one point-person for the Maine General Lab for drug screens and one for all other lab work (Nurse).Our randomization of urinalyses for drug/alcohol detection implemented by the Co-Occurring Specialist has been adapted to meet the MaineCare standards in order for lab work to be funded (no more than one time in 7 days).



Aspect: INDIVIDUAL SERVICE PLANS AND PROGRESS NOTES

Indicators

Findings

Compliance

Threshold

Percentile

1. Progress notes in GAP/Incidental/Contact format will indicate at minimum weekly contact with all clients assigned on an active status caseload.

36/40

80%

95%

2. Individual Service Plans will have measurable goals and interventions listing client strengths and areas of need related to community integration and increased court ordered privileges based on risk reduction activities.

38/40

90%

95%

3. Case notes will indicate at minimum monthly contact with all NCR clients who remain under the care of the Commissioner. These clients receive treatment services by community providers and RPC ACT monitors for court order and annual report compliance only.

10/10

100%

95%

Summary

1. Team now offers four groups, creating increased capacity for face-to-face contacts and supporting documentation. Clients in transition from ACT to other community resources have had less than weekly direct contact but are discussed weekly in clinical meeting and are seen face to face at least 4 times per month (averaging weekly contacts).

2. ISPs also contain group attendance goals, especially with clients who are petitioning for increased court ordered privileges. Case managers are focused on including group attendance in ISP goals.

3. One client in an outlying status petitioned for increased privileges for the July 12, 2011 docket.

Aspect: Peer Support

Indicators

Findings

Compliance

Threshold

Percentile

1. Engagement attempt with client within 7 days of admission.

1/2

50%

95%

2. Documented offer of peer support services.

2/2

100%

95%

3. Attendance at treatment team meetings as appropriate.

15/30

50%

95%

Summary

As in prior report, Peer Support Specialist makes every effort to attend treatment team meetings at ACT offices and in hospital; this quarter the Peer Support Specialist returned to work mid-May so 50% of the reporting period saw excellent results. The number and quality of contacts with clients by Peer Support continues to contribute to the ACT Teams goal of seeing clients face to face three times per week, and when needed, Peer Support Specialists from the hospital have met with clients of the ACT Team in the absence of the ACT PSP.


CAPITOL COMMUNITY CLINIC

CO

ASPECT: Dental clinic SURVEY

Indicators

Findings

Compliance

Threshold Percentile

Clients from RPC as well as clients in the community will receive a survey to fill out at the time of appt. The survey has several questions and in those questions we are asking the client how we can better serve there needs.

AprilTwenty-four surveys done by in-house clients as well as outpatient, all were positive.

100%

90%

MayNine surveys done by in-house clients as well as outpatient, all were positive.

100%

90%

JuneFifteen surveys done by in-house clients as well as outpatient, all were positive.

100 %

90%

Summary

Forty-eight surveys were returned and all showed positive results for the third quarter.

Actions

Will continue the client surveys to monitor and evaluate weekly as well as monthly with staff.



ASPECT: Dental Clinic 24 hour Post Extraction Follow-up

Indicators

Findings

Compliance


a. All clients with tooth extractions, will be assessed and have teaching post procedure, on the following topics, as provided by the Dentist or Dental Assistant

· Bleeding

· Swelling

· Pain

· Muscle soreness

· Mouth care

· Diet

· Signs/symptoms of infection

b. The client, post procedure tooth extraction, will verbalize understanding of the above by repeating instructions given by Dental Assistant/Hygienist.

April

Eight extractions were performed. Post extraction instructions verbalized to each client. Client repeated back to Dental Assistant that they understood the instructions without difficulty.

100%

100%

May

Nine extractions were performed. Post extraction instructions verbalized to each client. Client repeated back to Dental Assistant that they understood the instructions without difficulty.

100%

100%

June

Three extractions were performed. Post extraction instructions verbalized to each client. Client repeated back to Dental Assistant that they understood the instructions without difficulty.

100%

100%

Summary

There were twenty extractions in the fourth quarter. All clients had been educated on each topic listed above with post extraction, after care instructions were given both orally and in writing. Clients had no issues repeating and understanding the oral instructions.

A follow up post procedure phone call is done to check on the client’s progress. Of the twenty-seven calls made, there were no issues or complications post procedure. Reports were reviewed at monthly staff meetings and forwarded quarterly to RPC.

ActionResults will be reviewed monthly by staff and will continue to report monthly to RPC.



ASPECT: Dental Clinic Timeout/Identification of Client

Indicators

Findings

Compliance


National Patent Safety Goals

Goal 1: Improve the accuracy of Client

Identification.

Capital Community Dental Clinic assures accurate client identification by asking the client to state his/her name and date of birth.

Goal 2: Verify the correct procedure and site for each procedure.

A time out will be taken before the procedure to verify location and number of the tooth to be extracted. The time out section is in the progress notes of the patient chart. This page will be signed by the Dentist as well as the dental assistant.

April

There were eight extractions for the month, The client was given a time out to identify extraction site, and asked to state their name and dob.

100 %

100%

May

There were nine extractions done for the month. The each client was given a time out to identify extraction site, and asked to state their name and dob.

100%

100%

June

There were three extractions done for the month. The each client was given a time out to identify extraction site, and asked to state their name and dob.

100%

100%

Summary:

In the 4th quarter 2011, twenty clients had extractions. In all twenty cases there is appropriate documentation of a time-out procedure prior to the extraction. The client was asked to identify the extraction site and was also asked to identify themselves by providing their full name and date of birth.

Actions

The dental clinic staff will continue to report and monitor performance of key safety strategies.



ASPECT: Med Management Clinic Appointment Assessment

Indicators

Findings

Compliance


All Outpatient clients will have Vital Signs and Weight recorded upon arrival for appointment.

April

Twenty-eight clients that had scheduled appointments had their vitals signs taken before their clinic appointment.

100%

100%

May

There were thirty-one clients scheduled for appointments during the month of February. All clients had vital signs taken before their appointment.

100%

100%

June

There were thirty clients scheduled for appointments. All clients had their vital signs taken before their clinic appointment.

100%

100%

Summary

For the third quarter there were 81 clients. All clients had their vitals taken before their scheduled appointment. This information was reviewed at monthly staff meetings and reports forwarded quarterly to RPC Quality Council.

Actions

Staff will continue to strive for 100% of the goal. Staff will monitor and report monthly, as well as quarterly to RPC.


CLIENT SATISFACTION

ASPECT: Client satisfaction with care

#

Indicators

Findings

Results

% Change

1

I am better able to deal with crisis.

39%

+5%

2

My symptoms are not bothering me as much.

29%

-34%

3

The medications I am taking help me control symptoms that used to bother me.

34%

-29%

4

I do better in social situations.

37%

-4%

5

I deal more effectively with daily problems.

21%

-23%

6

I was treated with dignity and respect.

26%

-18%

7

Staff here believed that I could grow, change and recover.

26%

-40%

8

I felt comfortable asking questions about my treatment and medications.

18%

-45%

9

I was encouraged to use self-help/support groups.

45%

-11%

10

I was given information about how to manage my medication side effects.

26%

+1%

11

My other medical conditions were treated.

16%

-25%

12

I felt this hospital stay was necessary.

8%

-23%

13

I felt free to complain without fear of retaliation.

8%

-20%

14

I felt safe to refuse medication or treatment during my hospital stay.

-11%

-30%

15

My complaints and grievances were addressed.

24%

-7%

16

I participated in planning my discharge.

37%

-29%

17

Both I and my doctor or therapist from the community were actively involved in my hospital treatment plan.

16%

-22%

18

I had an opportunity to talk with my doctor or therapist from the community prior to discharge.

34%

+15%

19

The surroundings and atmosphere at the hospital helped me get better.

26%

-8%

20

I felt I had enough privacy in the hospital.

34%

-7%


CLIENT SATISFACTION

#

Indicators

Findings

Results

% Change

21

I felt safe while I was in the hospital.

34%

0%

22

The hospital environment was clean and comfortable.

45%

+20%

23

Staff were sensitive to my cultural background.

18%

-1%

24

My family and/or friends were able to visit me.

45%

-8%

25

I had a choice of treatment options.

24%

-20%

26

My contact with my doctor was helpful.

32%

-27%

27

My contact with nurses and therapists was helpful.

37%

-22%

28

If I had a choice of hospitals, I would still choose this one.

21%

-20%

29

Did anyone tell you about your rights?

32%

-18%

30

Are you told ahead of time of changes in your privileges, appointments, or daily routine?

16%

-22%

31

Do you know someone who can help you get what you want or stand up for your rights?

29%

-18%

32

My pain was managed.

5%

-39%

ND = no data

Summary

Positive scores indicate satisfaction, while negative scores indicate dissatisfaction. Percentages are calculated using actual weighted scores and highest possible score for each indicator. The total number of respondents was 19. The first column indicates the score for 4th quarter and the second column shows increases/decreases from 3rd quarter. Overall satisfaction for 4th quarter decreased significantly, down 17% from last quarter.

Only four indicators increased, while the remainder decreased. The most significant drops in satisfaction were with the following items: staff here believed that I could grow, change and recover; I felt comfortable asking questions about my treatment and medications; my pain was managed.

There were only two significant increases in satisfaction which were in the following items: I had an opportunity to talk with my doctor or therapist from the community prior to discharge; the hospital environment was clean and comfortable.


CLIENT SATISFACTION

0

10

20

30

40

50

% Satisfaction

1st Qtr2nd Qtr3rd Qtr4th Qtr

Total Satisfaction

Total


COMPARATIVE STATISTICS

The comparative statistics reports include the following elements:

· Client Injury Rate

· Elopement Rate

· Medication Error Rate

·

HYPERLINK \l "Readmit"

30 Day Readmit Rate

·

HYPERLINK \l "RestNum"

Percent of Clients Restrained

· Hours of Restraint

· Percent of Clients Secluded

· Hours of Seclusion

· Confinement Events Analysis

· Confinement Events Management

· Medication Administration during Behavioral Events

In addition to the areas of performance listed above, each of the comparative statistics areas includes a graph that depicts the stratification of forensic and non-forensic (civil) services provided to clients. This is new information that is being provided by the National Association of State Mental Health Program Directors Research Institute, Inc. (NRI). NRI is charged with collecting data from state mental health facilities, aggregating the data and providing feedback to the facilities as well as report findings of performance to the Joint Commission.

According to NRI, “forensic clients are those clients having a value for Admission Legal Status of "4" (Involuntary-Criminal) and having any value for justice system involvement (excluding no involvement). Clients with any other combination of codes for these two fields are considered non-forensic.”

(Back to Comparative Statistics) (Back to Table of Contents)


Figure CD-29

Client Injury Rate

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

Injuries per 1000 patient days

Riverview

0.000.000.000.270.260.000.270.800.000.270.280.260.000.000.520.000.24

Ntl Mean

0.500.430.430.490.410.450.420.500.440.420.380.360.370.460.430.490.45

+1 StDev

1.321.131.011.210.961.080.931.231.171.130.920.831.041.071.081.190.95

JanFebMarAprMayJunJulAugSepOctNovDecJanFebMarAprMayJun

3rd SFQ 20104th SFQ 20101st SFQ 20112nd SFQ 20113rd SFQ 20114th SFQ 2011

G

O

O

D

This graph depicts the number of client injury events 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 client 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.

“Non-reportable” injuries include those that require: 1) No Treatment, or 2) Minor First Aid

Reportable injuries include those that require: 3) Medical Intervention, 4) Hospitalization or where, 5) Death Occurred.

· No Treatment – The injury received by a client 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 client 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 client 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 if resulted in, or complications of the injury lead to, the termination of the life of the injured client.

The comparative statistics graph only includes those events that are considered “Reportable” by NRI.



Client Injury Rate

Forensic Stratification

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00


Riverview

0.000.000.000.000.390.000.000.790.000.000.000.390.000.000.000.000.00

Ntl Mean

0.230.240.300.340.320.220.250.370.290.270.260.290.260.290.270.360.37



Client Injury Rate

Civil Stratification

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00


Riverview

0.000.000.000.770.000.000.770.800.000.850.820.000.000.001.770.000.74

Ntl Mean

0.560.510.550.560.480.530.500.580.510.500.520.460.470.550.470.590.58

Dorothea Dix

0.000.000.000.590.001.220.000.000.000.000.000.000.540.000.000.000.00



These graphs depict the number of client injury events stratified by forensic or civil classifications 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 hospital-wide results from the Dorothea Dix facility are compared to the civil population results at the Riverview facility due to the homogeneous nature of these two sample groups.



Client Injuries

Apr

May

Jun

4TH FQ 2011

Total

4

2

4

10

ASPECT: Severity of injury by Month

Severity

Apr

May

Jun

4TH FQ 2011

No Treatment

3

1

2

6

Minor First Aid

1

1

2

4

Medical Intervention Required

0

0

0

0

Hospitalization Required

0

0

0

0

Death Occurred

0

0

0

0

ASPECT: Type and Cause of Injury by Month

Type - Cause

Apr

May

Jun

4TH FQ 2011

Accident-Equipment Use

1

3

Accident-Fall Witnessed

3

3

Assault-Client to Client

1

1

2

4



Figure CD-28

Elopement

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

Elopements per 1000 patient days

Riverview

0.000.000.000.000.260.000.000.000.000.000.000.000.000.000.000.260.00

Ntl Mean

0.220.260.200.300.260.280.250.230.270.210.200.180.170.190.160.220.32

+1 StDev

1.251.250.811.691.551.331.190.811.070.820.820.680.560.720.550.70.98



G

O

O

D

This graph depicts the number of elopements that occurred for every 1000 inpatient days. For example, a rate of 0.25 means that 1 elopement occurred for each 4000 inpatient days.

An elopement is defined as any time a client is “absent from a location defined by the client’s privilege status regardless of the client’s leave or legal status.”



Elopement


0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00


Riverview

0.000.000.000.000.000.000.000.000.000.000.000.000.000.000.000.840.00

Ntl Mean

0.080.040.050.080.080.060.080.100.100.090.060.050.050.070.060.100.13



Elopement


0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00


Riverview

0.000.000.000.000.780.000.000.000.000.000.000.000.000.000.000.000.00

Ntl Mean

0.190.230.220.250.240.260.250.220.230.230.200.180.170.190.230.320.46

Dorothea Dix

1.521.132.174.031.630.611.131.151.141.780.003.091.093.512.180.591.13



This graph depicts the number of elopements stratified by forensic or civil classifications that occurred for every 1000 inpatient days. For example, a rate of 0.25 means that 1 elopement occurred for each 4000 inpatient days. The hospital-wide results from the Dorothea Dix facility are compared to the civil population results at the Riverview facility due to the homogeneous nature of these two sample groups.



Medication Errors

0.00

5.00

10.00

15.00

20.00

25.00

30.00

Events per 100 episodes of care

Riverview

0.920.005.411.802.732.701.8012.969.091.796.318.627.694.927.204.133.10

Ntl Mean

3.922.603.482.922.992.602.412.792.242.522.232.572.342.682.632.492.33

Nat Mean +1 StDev

14.467.009.896.567.976.745.716.524.835.254.876.955.165.655.435.454.53



G

O

O

D

This graph depicts the number of medication error events that occurred for every 100 episodes of care (duplicated client count). For example, a rate of 1.6 means that 2 medication error events occurred for each 125 episodes of care.



Medication Errors


0.00

5.00

10.00

15.00

20.00

25.00

30.00

Events per 100 Episodes of Care

Riverview

1.750.001.820.001.750.003.571.795.263.515.563.396.154.555.805.881.37

Ntl Mean

3.241.912.602.932.122.062.402.162.222.052.443.662.122.512.362.222.57



Medication Errors


0.00

5.00

10.00

15.00

20.00

25.00

30.00

Events per 100 Episodes of Care

Riverview

3.850.008.933.703.775.660.0019.237.550.003.518.771.925.367.141.895.36

Ntl Mean

3.152.143.002.992.722.222.462.562.242.262.032.012.392.372.342.462.69

Dorothea Dix

15.666.985.132.3810.133.5324.365.266.4113.583.4910.9812.3612.828.899.210.00



This graph depicts the number of medication error events stratified by forensic or civil classifications that occurred for every 100 episodes of care (duplicated client count). For example, a rate of 1.6 means that 2 medication error events occurred for each 125 episodes of care. The hospital-wide results from the Dorothea Dix facility are compared to the civil population results at the Riverview facility due to the homogeneous nature of these two sample groups.



30 Day Readmit

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

Percent of discharges that return in 30 days

Riverview

6.670.006.670.000.005.565.260.000.003.858.705.268.009.520.009.380.00

Ntl Mean

5.665.035.765.725.906.086.065.645.715.975.815.445.225.795.685.894.62

Nat Mean +1 StDec

11.8210.2412.0711.2313.1512.389.2811.0411.2112.0811.7510.8811.2213.7111.9912.519.63



G

O

O

D

This graph depicts the percent of discharges from the facility that returned within 30 days of a discharge of the same client from the same facility. For example, a rate of 10.0 means that 10% of all discharges were readmitted within 30 days.



30 Day Readmit


0.00

5.00

10.00

15.00

20.00

25.00

30.00

Percent of Discharges that Return in 30 Days

Riverview

0.000.000.000.000.0020.000.000.000.000.000.000.0025.009.090.007.690.00

Ntl Mean

2.493.303.042.262.813.382.843.113.274.645.213.423.534.214.184.513.53



30 Day Readmit


0.00

5.00

10.00

15.00

20.00

25.00

30.00

Percent of Discharges that Return in 30 Days

Riverview

16.670.0012.500.000.000.008.330.000.005.0014.296.254.7610.000.0010.530.00

Ntl Mean

8.198.037.828.018.418.728.388.348.198.568.098.327.938.078.398.197.26

Dorothea Dix

13.045.8814.815.8811.5414.296.0614.294.550.007.419.688.3311.540.0011.7610.00



This graph depicts the percent of discharges from the facility that returned within 30 days of a discharge of the same client from the same facility stratified by forensic or civil classifications. For example, a rate of 10.0 means that 10% of all discharges were readmitted within 30 days. The hospital-wide results from the Dorothea Dix facility are compared to the civil population results at the Riverview facility due to the homogeneous nature of these two sample groups.




0.00

5.00

10.00

15.00

20.00

25.00

Percent of clients restrained at lease once

Riverview

7.349.437.2111.7114.5511.8211.7112.049.098.117.276.965.136.565.696.614.65

Ntl Mean

6.325.906.196.136.576.266.166.666.316.746.306.326.536.296.646.696.54

Nat Mean +1 St Dev

13.7512.6613.4513.7914.7114.3113.6314.6213.8315.3814.413.9713.9413.5413.6814.6513.7



G

O

O

D

This graph depicts the percent of unique clients who were restrained at least once – includes all forms of restraint of any duration. For example, a rate of 4.0 means that 4% of the unique clients served were restrained at least once.





0.00

5.00

10.00

15.00

20.00

25.00

Percent of Clients Restrained At Least Once

Riverview

8.7710.713.648.775.263.451.795.363.515.267.413.4504.552.92.941.37

Ntl Mean

3.793.123.693.693.73.863.923.893.453.413.643.763.823.384.093.794.41





0.00

5.00

10.00

15.00

20.00

25.00

Percent of Clients Restrained At Least Once

Riverview

5.778.0010.7114.8124.5321.1521.8219.2315.0911.117.1410.5311.548.939.2611.328.93

Ntl Mean

5.595.315.635.445.725.445.485.655.685.935.85.86.015.646.026.596.6

Dorothea Dix

10.987.146.4112.205.199.417.797.895.064.946.026.178.145.135.758.005.26



This graph depicts the percent of unique clients who were restrained at least once stratified by forensic or civil classifications – includes all forms of restraint of any duration. For example, a rate of 4.0 means that 4% of the unique clients served were restrained at least once. The hospital-wide results from the Dorothea Dix facility are compared to the civil population results at the Riverview facility due to the homogeneous nature of these two sample groups.



Figure CD-24

Restraint Hours

0.00

0.50

1.00

1.50

2.00

2.50

Restraint hours per 1000 inpatient hours

Riverview

0.110.090.010.070.030.050.130.120.070.050.110.060.010.060.030.100.02

Ntl Mean

0.360.410.480.370.390.380.330.360.340.330.340.300.360.370.380.470.39

Nat Mean +1 StDev

1.331.631.991.311.441.31.11.141.091.031.121.021.361.331.161.621.17



G

O

O

D

This graph depicts the number of hours clients spent in restraint for every 1000 inpatient hours - includes all forms of restraint of any duration. For example, a rate of 1.6 means that 2 hours were spent in restraint for each 1250 inpatient hours.



Restraint Hours


0.00

0.50

1.00

1.50

2.00

2.50

Restraint Hours per 1000 Inpatient Hours

Riverview

0.140.090.000.060.010.020.030.110.010.020.170.010.000.030.000.100.00

Ntl Mean

0.650.610.780.530.640.670.570.540.480.410.340.380.500.480.540.640.66



Restraint Hours


0.00

0.50

1.00

1.50

2.00

2.50

Restraint Hours per 1000 Inpatient Hours

Riverview

0.050.090.020.080.070.100.260.130.150.080.040.130.030.100.080.090.04

Ntl Mean

0.420.410.420.400.370.400.340.310.300.350.400.330.360.400.420.420.39

Dorothea Dix

0.030.010.010.010.010.010.010.050.010.000.000.010.020.010.010.010.00



This graph depicts the number of hours clients spent in restraint for every 1000 inpatient hours stratified by forensic or civil classifications - includes all forms of restraint of any duration. For example, a rate of 1.6 means that 2 hours were spent in restraint for each 1250 inpatient hours. The hospital-wide results from the Dorothea Dix facility are compared to the civil population results at the Riverview facility due to the homogeneous nature of these two sample groups.



Duration of Manual Hold (Restraint) Events

April - June 2011

13

5

3

11

22

4

0

5

10

15

20

25

1 min2 min3 min4 min5 min> 5 min

Number of Events

The overall number of manual hold events as well as the number of clients restrained for greater than 5 minutes increased insignificantly during the 4th quarter 2011. The overall increase in the number of manual holds was 9% during the period (from 53 to 58) and the increase in manual holds greater than 5 minutes was 10% (from 20 to 22).

Manual holds greater than 5 minutes most often result from a clinical assessment of the clients acuity and the potential for injury should the patient be left alone and without the control afforded by the manual hold. Those clients with the greatest number of manual holds over five minutes are usually suicidal, exhibit self injurious behaviors, or are highly psychotic and require one on one control that other methods of containment (e.g. seclusion) do not offer.

The decision on how each incident is managed is made on an individualized basis depending on the presentation and needs of the client. Each event is reviewed during the debriefing process and changes in methods of managing the events related to each client are evaluated to determine opportunities for improvement.



Duration of Manual Hold (Restraint) Events

Forensic and Civil Stratification

7

4

1

33

14

6

1

3

0

8

7

0

2

4

6

8

10

12

14

16

1 min2 min3 min4 min5 min> 5 min

Number of Events

Civil Forensic

The mix of manual hold incidents in this chart depicts the differentiation between the civil and forensic units.



Percent of Clients Secluded

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

Percent of clients secluded at lease once

Riverview

4.597.553.602.706.365.455.415.565.455.413.643.484.274.923.256.613.88

Ntl Mean

3.242.742.762.713.052.752.712.943.022.922.642.582.652.752.702.301.98

Nat Mean +1 St Dev

9.067.557.447.338.267.197.148.168.617.896.856.997.437.766.995.775.14



G

O

O

D

This graph depicts the percent of unique clients who were secluded at least once. For example, a rate of 3.0 means that 3% of the unique clients served were secluded at least once.





0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

Percent of Clients Secluded At Least Once

Riverview

5.265.361.821.753.513.451.793.573.515.263.701.721.541.520.004.412.74

Ntl Mean

2.602.312.322.582.722.702.562.632.512.151.932.072.111.972.201.792.32





0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

Percent of Clients Secluded At Least Once

Riverview

3.8510.005.363.709.437.699.097.697.555.563.575.267.698.937.419.435.36

Ntl Mean

2.722.412.552.442.652.442.502.462.522.512.462.472.632.412.642.462.01

Dorothea Dix

9.765.956.417.327.795.882.603.956.334.943.611.235.813.853.458.002.63



This graph depicts the percent of unique clients who were secluded at least once stratified by forensic or civil classifications. For example, a rate of 3.0 means that 3% of the unique clients served were secluded at least once. The hospital-wide results from the Dorothea Dix facility are compared to the civil population results at the Riverview facility due to the homogeneous nature of these two sample groups.



Figure CD-23

Seclusion Hours

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

Seclusion hours per 1000 inpatient hours

Riverview

0.551.480.080.110.120.260.160.230.270.650.270.060.410.240.100.270.18

Ntl Mean

0.390.370.330.420.530.480.420.440.420.400.330.330.350.400.330.270.22

Nat Mean +1 StDev

1.711.691.312.23.143.192.442.332.071.821.551.621.641.841.321.071.13



G

O

O

D

This graph depicts the number of hours clients 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.



Seclusion Hours


0.00

0.50

1.00

1.50

2.00

2.50

Seclusion Hours per 1000 Inpatient Hours

Riverview

0.622.300.010.030.060.120.10.260.180.430.430.010.570.0800.040.26

Ntl Mean

0.510.470.50.610.810.870.670.680.540.380.350.390.40.420.470.450.59



Seclusion Hours


0.00

0.50

1.00

1.50

2.00

2.50

Seclusion Hours per 1000 Inpatient Hours

Riverview

0.440.520.160.210.090.440.230.20.390.940.070.120.190.480.270.590.06

Ntl Mean

0.520.510.410.620.740.770.70.650.60.530.460.490.470.560.430.290.22

Dorothea Dix

0.930.250.530.350.430.160.230.160.270.100.090.231.930.130.050.330.07



This graph depicts the number of hours clients spent in seclusion for every 1000 inpatient hours stratified by forensic or civil classifications. For example, a rate of 0.8 means that 1 hour was spent in seclusion for each 1250 inpatient hours. The hospital-wide results from the Dorothea Dix facility are compared to the civil population results at the Riverview facility due to the homogeneous nature of these two sample groups.



Confinement Event Breakdown

Manual Hold

Mechanical Restraint

Locked Seclusion

Open Seclusion

Grand Total

% of Total

Cumulative %

FR0000284430

19

33

52

45%

45%

FR0000250266

13

3

16

14%

59%

FR0000291906

3

4

7

6%

65%

FR0000278119

3

2

5

4%

70%

FR0000269597

1

2

3

3%

72%

FR0000261594

1

3

4

3%

76%

FR0000266668

2

2

2%

77%

FR0000265736

1

1

2

2%

79%

FR0000274597

1

1

1

3

3%

82%

FR0000276436

2

2

2%

83%

FR0000285262

2

2

2%

85%

FR0000287797

1

1

2

2%

87%

FR0000084616

1

1

1%

88%

FR0000253377

2

2

2%

90%

FR0000273532

1

1

2

2%

91%

FR0000275370

1

1

1%

92%

FR0000277319

1

1

2

2%

94%

FR0000284901

1

1

1%

95%

FR0000289603

1

1

2

2%

97%

FR0000279315

1

1

1%

97%

FR0000281485

1

1

1%

98%

FR0000285866

1

1

1%

99%

FR0000273516

1

1

1%

100%

27% (23/84) of average hospital population experienced some form of confinement event during the 4th fiscal quarter 2011. Eleven of these clients (13% of the average hospital population) accounted for 85% of the containment events.

Confinement Events by Time of Day

0000-0359

0400-0759

0800-1159

1200-1559

1600-1959

2000-2359

FR0000284430

4

4

22

8

14

FR0000250266

3

4

3

2

4

FR0000291906

1

3

2

1

FR0000278119

2

1

2

FR0000261594

2

2

FR0000269597

2

1

FR0000274597

2

1

FR0000253377

1

1

FR0000265736

2

FR0000266668

1

1

FR0000273532

2

FR0000276436

1

1

FR0000277319

2

FR0000285262

1

1

FR0000287797

2

FR0000289603

2

FR0000084616

1

FR0000273516

1

FR0000275370

1

FR0000279315

1

FR0000281485

1

FR0000284901

1

FR0000285866

1



Figure CD-25, CD-26

Factors of Causation Related to All Confinement Events

(Manual Hold, Mechanical Restraint, Seclusion)

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Danger to Others/Self

6

18

6

5

2

1

15

33

27

27

17

57

Danger to Others

8

11

7

3

5

6

4

1

5

1

7

Danger to Self

3

1

3

4

1

2

1

1

% Dangerous Precipitation

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

Total Events

17

30

16

12

8

9

19

35

27

33

18

64



Figure CD-42

Confinement Events Management

Seclusion Events (56) Events

Standard

Threshold

Compliance

The record reflects that seclusion was absolutely necessary to protect the patient from causing physical harm to self or others, or if the patient was examined by a physician or physician extender prior to implementation of seclusion, to prevent further serious disruption that significantly interferes with other patients’ treatment.

95%

100%

The record reflects that lesser restrictive alternatives were inappropriate or ineffective. This can be reflected anywhere in record.

90%

100%

The record reflects that the decision to place the patient in seclusion was made by a physician or physician extender.

90%

100%

The decision to place the patient in seclusion was entered in the patient’s records as a medical order.

90%

100%

The record reflects that, if the physician or physician extender was not immediately available to examine the patient, the patient was placed in seclusion following an examination by a nurse.

90%

100%

The record reflects that the physician or physician extender personally evaluated the patient within 30 minutes after the patient has been placed in seclusion, and if there is a delay, the reasons for the delay.

90%

100%

The record reflects that the patient was monitored every 15 minutes. (Compliance will be deemed if the patient was monitored at least 3 times per hour.)

90%

100%

Individuals implementing seclusion have been trained in techniques and alternatives.

90%

100%

The record reflects that reasonable efforts were taken to notify guardian or designated representative as soon as possible that patient was placed in seclusion.

75%

100%

Standard

Threshold

Compliance

The medical order states time of entry of order and that number of hours in seclusion shall not exceed 4.

85%

100%

The medical order states the conditions under which the patient may be sooner released.

85%

100%

The record reflects that the need for seclusion is re-evaluated at least every 2 hours by a nurse.

90%

100%

The record reflects that the 2 hour re-evaluation was conducted while the patient was out of seclusion room unless clinically contraindicated.

70%

100%

The record includes a special check sheet that has been filled out to document reason for seclusion, description of behavior and the lesser restrictive alternatives considered.

85%

100%

The record reflects that the patient was released, unless clinically contraindicated, at least every 2 hours or as necessary for eating, drinking, bathing, toileting or special medical orders.

85%

100%

Reports of seclusion events were forwarded to medical director and advocate.

90%

100%

The record reflects that, for persons with mental retardation, the regulations governing seclusion of clients with mental retardation were met.

85%

100%

The medical order for seclusion was not entered as a PRN order.

90%

100%

Where there was a PRN order, there is evidence that physician was counseled.

95%

N/A



Figure CD-43

Confinement Events Management

Mechanical Restraint Events (1) Events

Standard

Threshold

Compliance

The record reflects that restraint was absolutely necessary to protect the patient from causing serious physical injury to self or others.

95%

100%

The record reflects that lesser restrictive alternatives were inappropriate or ineffective.

90%

100%

The record reflects that the decision to place the patient in restraint was made by a physician or physician extender

90%

100%

The decision to place the patient in restraint was entered in the patient’s records as a medical order.

90%

100%

The record reflects that, if a physician or physician extended was not immediately available to examine the patient, the patient was placed in restraint following an examination by a nurse.

90%

100%

The record reflects that the physician or physician extender personally evaluated the patient within 30 minutes after the patient has been placed in restraint, or, if there was a delay, the reasons for the delay.

90%

100%

The record reflects that the patient was kept under constant observation during restraint.

95%

100%

Individuals implementing restraint have been trained in techniques and alternatives.

90%

100%

The record reflects that reasonable efforts taken to notify guardian or designated representative as soon as possible that patient was placed in restraint.

75%

100%

The medical order states time of entry of order and that number of hours shall not exceed four.

90%

100%

The medical order shall state the conditions under which the patient may be sooner released.

85%

100%

Standard

Threshold

Compliance

The record reflects that the need for restraint was re-evaluated every 2 hours by a nurse.

90%

100%

The record reflects that re-evaluation was conducted while the patient was free of restraints unless clinically contraindicated.

70%

100%

The record includes a special check sheet that has been filled out to document the reason for the restraint, description of behavior and the lesser restrictive alternatives considered.

85%

100%

The record reflects that the patient was released as necessary for eating, drinking, bathing, toileting or special medical orders.

90%

100%

The record reflects that the patient’s extremities were released sequentially, with one released at least every fifteen minutes.

90%

100%

Copies of events were forwarded to medical director and advocate.

90%

100%

For persons with mental retardation, the applicable regulations were met.

85%

100%

The record reflects that the order was not entered as a PRN order.

90%

100%

Where there was a PRN order, there is evidence that physician was counseled.

95%

N/A

A restraint event that exceeds 24 hours will be reviewed against the following requirement: If total consecutive hours in restraint, with renewals, exceeded 24 hours, the record reflects that the patient was medically assessed and treated for any injuries; that the order extending restraint beyond 24 hours was entered by Medical Director (or if the Medical Director is out of the hospital, by the individual acting in the Medical Director’s stead) following examination of the patient; and that the patient’s guardian or representative has been notified.

90%

100%


comparative statistics

Medication Administration during Behavioral Events

Jan

Feb

Mar

Apr

May

Jun

Total

COURTN

3

1

2

6

COURTY

1

1

GUARDN

2

6

9

12

2

1

32

GUARDY

7

11

7

4

1

30

PEMEDSN

1

4

1

3

1

8

18

PEMEDSY

1

2

5

6

5

13

32

PRNY

10

14

11

11

12

31

89

Total Meds Admin

14

36

37

40

25

56

208

Percent Unwilling

21.43%

35.22%

27.03%

40.00%

12.00%

19.64%

26.92%

4th SFQ 2011

Abuse

Elopement

Manual Hold

Patient Incident

Patient Injury

Mechanical Restraint

Locked Seclusion

COURTN

2

1

COURTY

1

GUARDN

9

4

2

GUARDY

5

6

1

PEMEDSN

4

3

5

PEMEDSY

1

14

9

PRNY

1

1

6

28

2

16

1

Total

1

1

27

57

2

33

1

The high incidence of co-occurring manual holds and medication administrations, especially those that were given unwillingly, may have resulted from the need to temporarily secure the client and protect their safety during the administration of an intramuscular injection of ordered medication.

4th SFQ 2011

COURTN

GUARDN

PEMEDSN

TOTAL

FR0000250266

11

11

FR0000291906

4

4

FR0000253377

2

2

FR0000265736

1

1

FR0000266668

1

1

FR0000269597

1

1

FR0000273516

1

1

FR0000274597

1

1

FR0000277319

1

1

FR0000279315

1

1

FR0000281485

1

1

FR0000284430

1

1

FR0000285262

1

1

FR0000285866

1

1

FR0000287797

1

1

FR0000289603

1

1

Total

3

15

12

30

Average daily census for the period was 84 clients per day. The number of clients that received medication unwillingly was 19% of the average client census. All unwilling administrations of medications were supported by a court order, a guardian order, or the declaration of a psychiatric emergency.

COURTN = Court ordered medication administration, client unwilling

COURTY = Court ordered medication administration, client willing

GUARDN = Guardian permission for medication administration, client unwilling

GUARDY = Guarding permission for medication administration, client willing

PEMEDSN = Psychiatric Emergency declared, client unwilling

PEMEDSY = Psychiatric Emergency declared, client willing

PRNY = PRN medications offered, client willing


DIETARY

ASPECT: Cleanliness of Main Kitchen

Indicators

Quarterly

% Compliance


April 2011-

June 2011

Jan. ’11-

Mar. ‘11

Oct. ’10-

Dec. ‘10

Jul. ’10-

Sep. ‘10

Apr. ’10-

Jun. ‘10

Jan. ’10-

Mar. ‘10

1. All convection ovens (4) were thoroughly cleaned monthly.

100%

(12 of 12)

100%

(12 of 12)

75%

(9 of 12)

92%

(11 of 12)

83%

(10 of 12)

92%

(11 of 12)

100%

2. Dish machine was de-limed monthly

100%

(3 of 3)

100%

(3 of 3)

100%

(3 of 3)

100%

(3 of 3)

100%

(3 of 3)

100%

(3 of 3)

100%

3. Shelves (6) used for storage of clean pots and pans were cleaned monthly

100%

(9 of 9)

100%

(18 of 18)

100%

(18 of 18)

100%

(18 of 18)

100%

(18 of 18)

89%

(16 of 18)

100%

4. Knife cabinet was thoroughly cleaned monthly

100%

(3 of 3)

100%

(3 of 3)

100%

(3 of 3)

100%

(3 of 3)

100%

(3 of 3)

100%

(3 of 3)

100%

5. Walk in coolers were cleaned thoroughly monthly.

100%

(6 of 6)

100%

(6 of 6)

100%

(6 of 6)

100%

(6 of 6)

100%

(6 of 6)

100%

(6 of 6)

100%

6. Steam kettles (2) were cleaned thoroughly on a weekly basis

100%

(26 of 26)

100%

(26 of 26)

69%

(18 of 26)

93%

(26 of 28)

93%

(26 of 28)

79%

(19 of 24)

95%

7. All trash cans (4) and bins (1) were cleaned daily

97%

(530 of 546)

89%

(401 of 450)

98.9%

(455 of 460)

97%

(445 of 460)

85%

(462 of 546)

63%

(341 of 540)

95%

8. All carts(9) used for food transport (tiered) were cleaned daily

99.4%

(814 of 819)

97.7%

(792 of 810)

98%

(812 of 828)

98%

(811 of 828)

97%

(794 of 819)

85%

(686 of 810)

100%

9. All hand sinks (4) were cleaned daily

100%

(364 of364)

100%

(360 of 360)

95.6%

(352 of 368)

98%

(360 of 368)

92%

(794 of 819)

84%

(304 of 360)

95%

10. Racks(3) used for drying dishes were cleaned daily

98.9%

(270 of 273)

98.8%

(267 of 270)

99%

(273 of 276)

99%

(273 of 276)

81%

222 of 273

77%

(207 of 270)

100%

Summary

These indicators are based on state and federal compliance standards. Sanitary conditions shall be maintained in the storage, preparation and distribution of food throughout the facility. Written cleaning and sanitizing assignments shall be posted and implemented for all equipment, food contact surfaces, work areas and storage areas.

· The improvement seen in the cleaning of the trash cans and bins is due to employee compliance

(Back to Table of Contents)DIETARY

· and comprehension of the task.. · Cleaning the food transport carts and cleaning the racks used for drying dishes improved slightly to 98.9%Overall Compliance: 98.8%

Actions· FSM reviews all cleaning schedules on a daily basis to assure staff completion.

· Cleaning schedules are modified to reflect changes in staff availability.

· Weekly staff meetings include review of the past weeks completion rates.

· Results of this CPI indicator will be discussed with staff.

· The department will be fully staffed as of August 2011.

ASPECT: TIMELINESS OF NUTRITIONAL ASSESSMENT

Indicator

Quarterly

% Compliance


April 2011-

June 2011

Jan. ’11-

Mar. ‘11

Oct. ’10-

Dec. ‘10

Jul. ’10-

Sep. ‘10

A nutrition assessment is completed within 5 days of admission when risk is identified via the nutrition screen.

100%

(76 of 76)

100%

(75 of 75)

97.4%

(74 of 76)

100%

(59 of 59)

(New Indicator)

100%

Summary

All assessments completed within 5 days of admission.

Overall Compliance: 100% Actions

· The nutrition screen, which is part of the Initial Nursing Assessment and Admission Data, will be completed by nursing within 24 hours of admission.

· The Dietitian reviews the nutrition screening to determine whether the client is at nutrition risk.

· Nursing will contact the Dietary Department at 287-7248 if an Urgent consult is required. Dietary staff will then contact the Registered Dietitian/Dietetic Technician Registered. This includes weekends and holidays. The RD/DTR will respond by telephone or with an on-site follow-up as deemed appropriate within 24 hours. Nursing must document in the progress notes any recommendations made by the RD/DTR.


HARBOR TREATMENT MALL

Aspect: Harbor Mall Hand-off Communication

Indicators

Findings

Compliance

Threshold

Percentile

1. Hand-off communication sheet was received at the Harbor Mall within the designated time frame.

26 of 42

62%

100%

2. RN signature/Harbor Mall staff signatures present.

42 of 42

100%

100%

3. SBAR information completed from the units to the Harbor Mall.

23 of 42

55%

100%

4. SBAR information completed from the Harbor Mall to the receiving unit.

30 of 42

71%

100%

Summary

This is the second quarterly report for this year. All units were made aware of the criteria that would be monitored in order to ensure that the hand-off communication process for the Harbor Mall is being done properly. Indicators number one and two remain the same as the first quarter, indicator number three increased from 52% to 55% and indicator number four increased from 55% to 71% from the first quarter.

Indicator #1-Sixteen of the hand-off communication sheets did not arrive to the Harbor Mall within the allotted time frame. The sheet is to be brought to the mall no later than 5 minutes before the start of groups and this did not happen on sixteen of the sheets that were reviewed for this quarter. The PSD for the mall will remind each of the units what the protocol is for the hand-off sheet to ensure that the information reaches the mall in time to be relayed to group leaders.

Indicator #2- All hand-off communication sheets were received with RN signatures and signed off as received by the Harbor Mall. No issues at this time.

Indicator #3- Nineteen out of the 42 sheets reviewed did not have any client concerns or comments from the unit(s) written for the Harbor Mall and/or did not state no issues to report on the HOC. PSD for the Harbor Mall will review the need for accuracy in completing the HOC sheet with each of the units.

Indicator #4 – Twelve out of the 42 sheets reviewed did not have any client concerns or comments from the Harbor Mall back to the units and/or did not state know issues to report on the HOC sheet. PSD will remind Harbor Mall staff to complete issues/concerns section.

Actions

The PSD will continue to randomly audit all the hand-off communication sheets received from the units. Any patterns from one particular unit will be reported to that unit’s PSD in order to ensure accurate and timely communication between the two areas.


HEALTH INFORMATION MANAGEMENT

ASPECT: Documentation & Timeliness

Indicators

Findings

4th Qtr 2011

3rd Qtr 2011


Records will be completed within Joint Commission standards, state requirements and Medical Staff bylaws timeframes.

There were 67 discharges in the 4th quarter 2011. Of those, 53 were completed by 30 days.

79 %

49 %

80%

Discharge summaries will be completed within 15 days of discharge.

67 out of 67 discharge summaries were completed within 15 days of discharge during the 4th quarter 2011.

100 %

100 %

100%

All forms/revisions to be placed in the medical record will be approved by the Medical Records Committee.

1 forms was approved/ revised in the 4th quarter 2011 (see minutes).

100%

100%

100%

Medical transcription will be timely and accurate.

Out of 1310 dictated reports, 1121 were completed within 24 hours.

86%

84%

90%

Summary

The indicators are based on the review of all discharged records. There was 79% compliance with record completion. There was 100% compliance with discharge summary completion. Weekly “charts needing attention” lists are distributed to medical staff, including the Medical Director, along with the Superintendent, Risk Manager and the Quality Improvement Manager. There was 86% compliance with timely & accurate medical transcription services.

Actions

Continue to monitor the compliance rate of each measure and work closely with the Medical Director to identify barriers to on-time completion of medical records according to the prescribed timeline.


HEALTH INFORMATION MANAGEMENT

ASPECT: Confidentiality

Indicators

Findings

Compliance


All client information released from the Health Information department will meet all Joint Commission, State, Federal & HIPAA standards.

3501 requests for information (128 requests for client information and 3373 police checks) were released for the 4th quarter 2011.

100%

100%

All new employees/contract staff will attend confidentiality/HIPAA training.

16 new employees/contract staff in the 4th quarter 2011.

100%

100%

Confidentiality/Privacy issues tracked through incident reports.

1 privacy-related incident reports during the 4th quarter 2011.

100%

100%

Summary

The indicators are based on the review of all requests for information, orientation for all new employees/contract staff and confidentiality/privacy-related incident reports. There was 1 confidentiality/privacy-related incident report in 4th quarter 2011. This was an external breach of confidentiality. To date, we have been unable to determine the source of the breach, however, the fact-finding is ongoing.

No problems were found in 4th quarter 2011 related to release of information from the Health Information department and training of new employees/contract staff, however compliance with current law and HIPAA regulations need to be strictly adhered to requiring training, education and policy development at all levels.

Actions

The above indicators will continue to be monitored.


HOUSEKEEPING

ASPECT: Linen Cleanliness and Quality

Indicators

Quarterly

% Compliance


Apr. ’11-

Jun. ‘11

Jan. ’11-

Mar. ‘11

Oct. ’10-

Dec. ‘10

Jul. ’10-

Sep. ‘10

Apr. ’10-

Jun. ‘10

Jan. ’10-

Mar. ‘10

1. Was linen clean coming back from vendor?

98%

(45 of 46)

100%

(34 of 34)

100%

(53 of 53)

96%

(23 of 24)

100%

(37 of 37)

100%

(32 of 32)

100%

2. Was linen free of any holes or rips coming back from vendor?

98%

(45 of 46)

92%

(31 of 34)

100%

(53 of 53)

92%

(22 of 24)

81%

(30 of 37)

97%

(31 of 32)

95%

3. Did we have enough linen on units via complaints from unit staff?

98%

(45 of 46)88%

(30 of 34)

96%

(51of 53)

92%

(22 of 24)

97%

(36 of 37)

94%

(30 of 32)

90%

4. Was linen covered on units?

100%

(46 of 46)97%

(33 of 34)

100%

(53 of 53)

100%

(24 of 24)

100%

(37 of 37)

88%

(28 of 32)

95%

5. Did vendor provide a 24 hr. turn around service as specified in the contract?

96%

(44 of 46)97%

(33 of 34)

96%

(51 of 53)

79%

(19 of 24)

95%

(35 of 37)

94%

(30 of 32)

100%

6. Did we receive an adequate supply of mops and rags from vendor?

98%

(45 of 46)97%

(33 of 34)

100%

(53 of 53)

100%

(24 of 24)

100%

(37 of 37)

97%

(31 of 32)

95%

7. Was linen bins clean returning from vendor?

87%

(40 of 46)100%

(34 of 34)

100%

(53 of 53)

100%

(24 of 24)

97%

(36 of 37)

100%

(32 of 32)

100%

8. Was the linen manifest accurate from the vendor

89%

(41 of 46)88%

(30 of 34)

96%

(51 of 53)

31%

(5 of 16)

(New)

85%

Summary

Eight different criteria are to be met for acceptability. The indicators are based on the inspections of linen closets throughout the facility including the returned linen from the vendor. All linen types were reviewed randomly this quarter. All indicators are within threshold percentiles except for indicators #1, #5, & #7.

The overall compliance for this quarter was 95.5%. This is shows a .5% increase from last quarters’ report.

1. (Indicator #1) inadequate supply of linen (blankets) were not coming back from vendor

2. Linen coming back from the vendor was not delivered to Riverview in a timely fashion (2 occurrences) (indicator # 5).


HOUSEKEEPING

3. Linen bins that were returned from vendor with clean linens were found to be dirty (Indicator #

Overall Compliance: 95.5% Actions

The Housekeeping Department has done the following actions to remedy the above problem indicators:

· Housekeeping Supervisor will monitor how many blankets are being sent out to be cleaned and how many return from vendor.

· Housekeeping Supervisor contacted the linen vendor and advised them of the problems with dirty linen bins returning from their facility.

· Communicate to all Housekeeping staff to be aware of the status of this indicator.

· Housekeeping staff member will continue to document all information regarding to inventory and manifest statistics from the vendor.

· Housekeeping Supervisor will monitor the timeliness of linen deliveries.

· Housekeeping Supervisor will schedule a visit to the linen cleaning facility to see how the linen processing is done.


HUMAN RESOURCES

ASPECT: Direct Care Staff Injuries

Reportable (Lost Time & Medical) Direct Care Staff Injuries

1.31

0.78

0.84

0.41

2.25

0.00

0.44

1.19

0.00

1.22

0.45

2.03

0.00

0.50

1.00

1.50

2.00

2.50

Jul-10

Aug-10Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11Mar-11

Apr-11

May-11

Jun-11

Per 1,000 Patient Days

Summary

The trend for reportable injuries sustained by direct care staff increased during the month of June.

The greatest percentage of injuries with direct care staff tend to be related to client to staff interactions. Current work on developing tools to reduce the incidence of physical interaction between clients and staff through heightened awareness of client’s triggers and coping mechanisms appear to be having an impact on the frequency of client to staff physical interactions. Any reduction in the number of these interactions may also impact the number of both client and staff injuries that may result from these interactions.


HUMAN RESOURCES

ASPECT: Non-Direct Care Staff Injuries

Reportable (Lost Time & Medical) Non-Direct Care Staff Injuries

0.00

0.42

0.41

0.45

0.44

0.44

0.37

0.00

0.00

0.00

0.00

0.00

0.00

0.50

1.00

1.50

2.00

2.50

3.00

Jul-10

Aug-10Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11Mar-11

Apr-11

May-11

Jun-11

Per 1,000 Patient Days

Summary

The average percent of non-direct care staff who sought medical attention or lost time from work remains low. The annual trend shows a steady yet low rate of injury. As with the incidence of direct care staff injuries, close monitoring of surrounding events and activities is being conducted to determine correlations between injury rates and work activities.


HUMAN RESOURCES

ASPECT: Performance Evaluations completion

Completion of performance evaluations within 30 days of the due date.

Performance Evaluation Compliance

88.57%

100.00%

80.00%

72.73%

67.74%

80.00%

68.42%

85.71%

92.31%

90.91%

84.62%

87.95%

73.33%

81.58%

86.67%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Apr-10

May-10

Jun-10

Jul-10

Aug-10Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11Mar-11

Percent On-Time Completion

Monthly % Compliance Quarterly % Compliance

Summary

This quarter has shown some difficulties in maintaining a high degree of completion of performance evaluations.

Cumulative results from this quarter (73.33%) are below the planned performance threshold of 85%. The monthly results for compliance are also all below the planned performance threshold. These results are beginning to show a trend lower than planned performance as six data points are below the threshold level. Ongoing measurement of performance is indicated for the remainder of the calendar year. Ongoing efforts to insure on time completion of performance evaluations by unit managers will continue in order to achieve the highest possible rate of on-time performance and to maintain a sustainable level of performance above the 85% level.


HUMAN RESOURCES

ASPECT: Personnel Management

Overtime hours and mandated shift coverage

Monthly Ov

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