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QUARTERLY REPORT ON ORGANIZATIONAL PERFORMANCE EXCELLENCE

FIRST STATE FISCAL QUARTE R 2018 July, August, September 2017

Carolyn Dimek, RN, MS Acting Superintendent

November 15, 2017

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Table of Contents Introduction .............................................................................................................................. 2 Comparative Statistics .............................................................................................................. 3 Joint Commission:

Hospital Based Inpatient Psychiatric Services (HBIPS) ............................................... 12 Contract Management ................................................................................................ 13 Medication Management ........................................................................................... 15 Inpatient Consumer Survey ........................................................................................ 17 Fall Reduction Strategies ............................................................................................ 24 Pain Assessment ......................................................................................................... 28

Quality Assurance & Performance Improvement (QAPI):

Dietary ......................................................................................................................... 30 Facilities....................................................................................................................... 32 Health Information Management ............................................................................... 36 Infection Control ......................................................................................................... 40 Medical Staff ............................................................................................................... 47 Nursing ........................................................................................................................ 55 Outpatient & Forensic Services .................................................................................. 65 Pharmacy Services ...................................................................................................... 72 Risk Management ....................................................................................................... 80 Social Services ............................................................................................................. 84 Staff Education and Development .............................................................................. 88 Therapeutic Services ................................................................................................... 92

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Introduction This edition of the Dorothea Dix Psychiatric Center Quarterly Report on Organizational Performance Excellence is designed to address overall organizational performance in a systems improvement approach instead of a purely compliance approach. There are three major sections that make up this 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) 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.

COMPARATIVE STATISTICS

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Number of patient injury incidents that occurred for every 1000 inpatient days. For example, a rate of 0.5 means that one injury occurred for each 2000 inpatient days. The NRI standards for measuring patient injuries differentiate between injuries that are considered reportable to the Joint Commission as a performance measure and those injuries that are of a less severe nature. While all injuries are currently reported internally, only certain types of injuries are documented and reported to NRI for inclusion in the performance measure analysis process. This comparative statistic graph only includes those events that are considered “Reportable” by NRI.


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“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. 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.

Type and Cause of Injury by Month

Type - Cause July August September 1Q2018

Accident 1 1

Fall 1 1 1 3

Patient to Patient Incident 1 1 1 3

Self-Injurious Behavior

Other 1 1 2

Total 3 3 3 9

Severity of Injury by Month Severity July August September 1Q2018

No Treatment 1 2 2 5

Minor First Aid 2 1 1 4

Medical Intervention Required

Hospitalization Required

Death Occurred

Total 3 3 3 9


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Number of elopement incidents that occurred for every 1000 inpatient days. For example, a rate of 0.25 means that one elopement occurred for each 4000 inpatient days.


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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.


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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 five minutes be included in this indicator. For example, rates of 4.0 means that 4% of the unique patients served were restrained at least once, for any amount of time.


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Number of hour’s patients spent in restraint for every 1000 inpatient hours. For example, a rate of 1.6 means that two hours were spent in restraint for each 1250 inpatient hours.


9

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.


10

Number of hours patients spent in seclusion for every 1000 inpatient hours. For example, a rate of 0.8 means that one hour was spent in seclusion for each 1250 inpatient hours.


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Confinement Event Breakdown

Patient ID Manual

Hold Mechanical

Restraint Locked

Seclusion Grand Total

% of Total

Cumulative %

MD1305 21 6 27 62.79% 62.79%

MD2098 2 2 4 9.30% 72.09%

MD2129 3 3 6.98% 79.07%

MD2122 1 2 3 6.98% 86.05%

MD2127 1 1 2 4.65% 90.70%

MD2131 1 1 2 4.65% 95.35%

MD506 1 1 2.33% 97.67%

MD2132 1 1 2.33% 100.00%

31 1 11 43

Unit Manual

Hold Locked

Seclusion Event Jul Aug Sep

Chamberlain 28 8 Manual Hold 11 11 9

Hamlin 2 2 Locked Seclusion 5 5 1

Knox 1 1

JOINT COMISSION

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Hospital Based Inpatient Psychiatric Services (HBIPS) The Inpatient Psychiatric Facility Quality Reporting System (IPFQRS) measures are required by the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (the hospitals accrediting agency). These measures were created due to a request made to The Joint Commission in 2003 to identify and implement a set of core performance measures for hospital-based inpatient psychiatric services. The measures have changed over the years.

IPFQRS Measures

Oct

ob

er

20

16

No

vem

be

r 2

01

6

De

cem

be

r 2

01

6

Jan

uar

y 2

01

7

Feb

ruar

y 2

01

7

Mar

ch 2

01

7

Ap

ril 2

01

7

May

20

17

Jun

e 2

01

7

July

20

17

Au

gust

20

17

Sep

tem

be

r 2

01

7

HBIPS-1: Percent of inpatients screened within the first three days of admission for risk of violence to self or others, substance use, psychological trauma history, and patient strengths. TJC target: 95%

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

HBIPS-2: Number of hour’s patients spent in physical restraint for every 1000 inpatient hours. TJC target: < 0.49

0.17 0.08 0.01 0.06 0.01 0.01 0.01 0.01 0.00 0.01 0.03 0.01

HBIPS-3: Number of hour’s patients spent in seclusion for every 1000 inpatient hours. TJC target: < 0.36

0.61 0.15 0.28 0.23 0.11 0.07 0.14 0.20 0.14 0.25 0.24 0.03

HBIPS-5: Percept of patients with appropriate justification for discharge on multiple antipsychotic medications. TJC target: 61%

100% * 0% 100% 100% 100% 100% * 100% 100% 100% *

*No patients were discharged on multiple antipsychotics this month Note: TJC targets typically run approximately 6 months behind, and the TJC target above was for March 2017.

JOINT COMISSION

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Contract 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.

1Q2018 Results

Contractor Program Administrator Summary of Performance

Affiliated Laboratory Carolyn Dimek Acting Superintendent

All indicators exceeded standards.

Casella Waste Systems Mark Faulkner Director of Facilities

All indicators met standards.

CES, Inc. Mark Faulkner Director of Facilities

All indicators met or exceeded standards.

Comprehensive Pharmacy Services

Carolyn Dimek Acting Superintendent

One indicator did not meet standards: Pharmacist reviews and discusses with IPEC committee, Forum and P & T committee any areas requiring improvement. All other indicators met or exceeded standards.

Harriman Associates Mark Faulkner Director of Facilities


Liberty Healthcare Physicians and/or Mid-Levels On Call

Dr. Michelle Gardner Clinical Director


Liberty Healthcare Psychiatric Nurse Practitioner



MD-IT Transcription Michelle Welch Medical Records Administrator


Northeast Cardiology Associates (NECA)



Norris, Inc. Mark Faulkner Director of Facilities


Otis Elevator Mark Faulkner Director of Facilities


Penobscot Community Health Care (PCHC)



JOINT COMISSION

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Project Staffing Carol Davis Business Manager


Securitas Mark Faulkner Director of Facilities


UniFirst Mark Faulkner Director of Facilities

Two indicators did not meet standards: (1) Pickup and delivery turn-around times established were not adhered to and (2) linen received clean & neat in appearance at the hospital due to a lack of quality in the items received this quarter. One indicator met standards.

WBRC Architects Engineers Mark Faulkner Director of Facilities


Worldwide Travel Staffing Carolyn Dimek Acting Superintendent


JOINT COMISSION

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Medication Management Medication 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 two medication error events occurred for each 125 episodes of care.

JOINT COMISSION

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JOINT COMISSION

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Inpatient Consumer Survey 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 and the Inpatient Customer Survey.

The Inpatient Customer Survey (ICS) is a standardized national survey of customer satisfaction. The National Association of State Mental Health Program Directors Research Institute (NRI) collects data from state psychiatric hospitals throughout the country in an effort to compare the results of patient satisfaction in six areas or domains of focus. These domains include Outcomes, Dignity, Rights, Participation, Environment, and Empowerment.

NRI Inpatient Consumer Survey (ICS) Response Rate:

July August September 1Q2018

Number of patients discharged 9 7 7 23

Number of survey responses 5 4 1 10

Survey response rate 56% 57% 14% 43%

Note: The following graphs contain the results of the Inpatient Consumer Survey. If there is no result for a particular month, it indicates that no surveys were completed for that month.

JOINT COMISSION

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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 COMISSION

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Dignity Domain

1. I was treated with dignity and respect.

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

3. I felt comfortable asking questions about my treatment and medications.

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

JOINT COMISSION

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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 COMISSION

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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 COMISSION

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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 COMISSION

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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 COMISSION

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Fall Reduction Strategies

TJC PI.01.01. EP38 The hospital evaluates the effectiveness of all fall reduction activities including assessment, interventions and education.

JOINT COMISSION

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Fall Reduction Nursing Interventions Christine Bellatty, RN I. Measure Name: Patient Falls - Establishing a Culture of Safety

Measure 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.

All patient falls in 1Q2018

Falls risk assessment completed

Falls Progress Note 565 completed and in patient’s

medical record

14 (all met definition)

Yes: 9 No: 5 N/A: 0

Yes: 6 No: 0 N/A: 8

Overall Compliance

64% 100% 82%

**Question applicable for April 2017 only; the goal was met in April therefore this measure will no longer be reported on. Data Analysis: 1Q2018 shows 14 falls all meeting definition of a fall. Overall compliance is 82% with the decreased produced by incompletion of Fall Risk Assessment throughout the quarter.

JOINT COMISSION

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JOINT COMISSION

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Action Plan: Auditing Nurse Supervisor provides education to staff during auditing process. Nursing administration will continue to follow up and audit all falls. Due to decreased compliance in nursing documentation for Falls Risk Assessment, falls documentation packets will be formed, including 565R Falls Documentation Checklist, and distributed to each unit in order to increase patient safety and overall compliance.

JOINT COMISSION

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Pain Assessment Christine Bellatty, RN I. Measure Name: Pain Audit Shift Assessment - Patient Recovery

Measure 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. 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 2Q2017 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%.

Results

Target Data elements

Baseline Jan/Feb

2013 1Q2018 2Q2018 3Q2018 4Q2018 YTD

90% Compliance

Number of audits completed

36 104 104

Number of audits having 1 shift assessment completed that assesses for the presence and intensity of pain within 24 hours

12 100 100

Overall Compliance 33% 96% 96%

Data Analysis: 1Q2018 shows an increase above goal to 96%; this is a 4% increase from previous quarter.

JOINT COMISSION

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Action Plan: Nursing exceeded goal this Quarter. Nursing Administration will continue to collect data and monitor the process to ensure that pain is being assessed at least every 24 hours for every patient and documented. Clinical Nurse Managers will address staff members that are not completing these assessments. Clinical Nurse Managers or Charge Nurses will email Nursing Administration each week on Friday to report adherence to documentation procedure of pain.

QUALITY ASSURANCE & PERFORMANCE IMPROVEMENT

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Dietary Bobbie Lindsey

I. Measure Name: ServSafe Training Measure Description: ServSafe is a food and beverage safety training and certificate program administered by the National Restaurant Association Type of Measure: Quality Assurance

Results

Target

Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD

1Q2017 93%

100% 100% 100% 100% 100%

Actual 52% 52%

Data Analysis: The data indicates that we fell short of our goal of 100% certification by 48%. Action Plan: A class has been scheduled for November 16th to complete all certifications for both those who are not certified and for those who have certificates that have expired.

Comments: Wendy Schriver is now certified to teach and proctor the Serv-Safe class.


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II. Measure Name: Cleaning Schedule and Checklist

Measure Description: Dietary staff will complete and maintain proper sanitation process for kitchen equipment Type of Measure: Quality Assurance

Results

Target


1Q2018 49%

100% 100%

Actual 49%

63/129

49% 63/129

Methodology: The Food Service Manager or designee will verify completion of sanitation processes for kitchen equipment through validation of sanitation schedule and checklist to ensure equipment is clean and sanitary. The dietetic services workers will be responsible for documenting completion of each task. The supervisor will review the sheets and complete a sanitation inspection of the kitchen equipment on a weekly basis. Data Analysis:

• Some dish room daily duties were missed due to short staffing.

• Some dish room daily duties were either not completed or not signed off by staff member assigned to do them.

• Some cook duties were not completed due to short staffing.

• Monthly and weekly cook cleaning duties were missed due to staff not completing assigned duties or staff did not sign off on the check list.

• Monthly, bi-weekly and weekly FSW duties were missed due to staff not completing assigned duties or staff did not sign off on the check list.

• First Quarter: 92 days

• Cook Weekly duties: 14 total duties per week, 24 duties total not completed

• Cook Monthly duties: 13 total duties per month, 5 duties total not completed

• FSW Weekly duties: 12 total duties per week, 29 duties total not completed

• FSW Bi-Weekly duties: 2 total duties bi-weekly, 3 duties total not completed

• FSW Monthly duties: 2 total duties, 2 duties total not completed

Weekly duties were posted for the entire month, and this created a situation where staff would not complete the duty on the week they were assigned that duty. Duties were being missed or completed the next week when the employee was no longer responsible for that duty, and therefore the checklist was not being completed correctly. Action Plan: A new check list has been created and weekly duties are posted on a weekly basis.


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Facilities Mark Faulkner

I. Measure Name: Access Control Quality Assurance Measure Description: Measure the success of the hospitals ability to maintain access control for terminated (including resigned, retired, and transferred) employees. Type of Measure: Quality Assurance

Results

Target

Unit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD

Number of opportunities

for access control

verification

New Measure 1Q2018

88%

100% 100% 100% 100% 100%

Actual 88%

15/17

88% 15/17

Methodology: The Plant Maintenance Engineer will maintain a database of keys/badge received within 24 hours of termination (including resigned, retired, and transferred) of the employee. The Plant Maintenance Engineer will compare weekly with the terminated employee list provided by Human Resources to analyze effectiveness of the program. The numerator will be the total number of opportunities identified on the Facilities keys/badge database that were received within 24 hours and the denominator will be the total number of employees terminated that week according to the Human Resources terminated employee list. The performance percentage (performance ratio) will be the numerator divided by the denominator. Data Analysis: During the 1Q2018, 17 employees were terminated from employment per the terminated employee list provided by Human Resources. 15 keys/badges were received by Facilities within 24 hours for a success rate of 88%. Action Plan: None needed at this time.


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II. Measure Name: Main Entrance Sign Out/In Log Verification Measure Description: Analyze the Main Entrance Sign Out/In Log to verify contraband that is allowed for patient use off grounds (belts and shoelaces) is successfully removed upon reentry to the hospital. Verification of this will be done using the Incident Reports completed if contraband is found on the patient units. Type of Measure: Quality Assurance

Results

Target



for contraband

to enter

New Measure 1Q2018

100%

100% 100% 100% 100% 100%

Actual 100%

847/847

100% 847/847

Methodology: The Director of Facilities (DOF) and the Site Security Supervisor will perform quarterly audits of the main entrance sign out/in log to verify that all contraband allowed for patient use off grounds is successfully removed and logged upon re-entry to the hospital. Verification of successful screenings will be conducted by referencing incident reports completed if contraband allowed for patient use off grounds is found on patient units. The denominator will be the total number of opportunities identified in the main entrance sign out/in log with the numerator being the total number of incident reports completed where contraband was found on a patient unit that should have been removed upon re-entry from an off grounds pass. The performance percentage (performance ratio) will be the numerator divided by the denominator. Data Analysis: During 1Q2018, 847 opportunities for contraband to re-enter the hospital were identified by using the main entrance sign out/in log that indicates contraband allowed for patient use off grounds. 847 items listed were removed upon re-entry to the hospital resulting in zero incident reports of contraband found on a patient unit resulting from main entrance sign out/in contraband log for a 100% success rate. Action Plan: None needed at this time.


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III. Measure Name: Personal Protective Equipment Assessments Measure Description: Personal Protective Equipment (PPE) Assessments will be conducted randomly on employees performing tasks associated with the need to use PPE. Type of Measure: Performance Improvement

Results

Target



for PPE Assessment

New Measure 1Q2018

93%

100% 100% 100% 100% 100%

Actual 93%

14/15

93% 14/15

Methodology: The Institutional Safety & Maintenance Director and the Director of Facilities will perform 15 unannounced PPE Assessments per quarter to ensure proper PPE is being utilized during tasking. Partial Hazard Communication Program effectiveness will be assessed by using data from the opportunity to properly comply with the Hazard Communication Program versus non-compliance. The denominator will be the total number of unannounced PPE Assessments conducted during the quarter for Facilities staff conducting tasking that requires PPE. The numerator will be the total number of PPE assessments conducted during the quarter for Facilities staff where proper PPE was utilized while performing tasking that requires PPE. The performance percentage (performance ratio) will be the numerator divided by the denominator. Data Analysis: During 1Q2018, 15 Personal Protective Equipment Assessments were performed. Of the 15 assessments performed, 14 were performing tasking while utilizing the proper PPE; therefore, the overall compliance rate for the quarter is 93%. Action Plan: None needed at this time.


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IV. Measure Name: Employee Efficiency Audits Measure Description: Employee efficiency audits will be conducted by Facilities Department Managers to assess for timely work completion and employee work performance. Type of Measure: Performance Improvement

Results

Target


Number of opportunities for Employee

Efficiency Audits

New Measure 1Q2018

70%

100% 100% 100% 100% 100%

Actual 70%

14/20

70% 14/20

Methodology: Facilities Department managers will perform 20 unannounced employee efficiency audits per quarter to ensure employee efficiency, timely work completion, employee work performance, and employee effectiveness during scheduled work hours. The denominator will be the total number of unannounced employee efficiency audits conducted during the quarter for Facilities staff performing work. The numerator will be the total number of employee efficiency audits conducted during the quarter for Facilities staff who were performing tasking in an efficient and effective manner. The performance percentage (performance ratio) will be the numerator divided by the denominator. Data Analysis: During 1Q2018, 20 employee efficiency audits were performed. Of the 20 audits performed, 14 were performing tasking in an efficient and effective manner; therefore, the overall compliance rate for the quarter is 70%. Action Plan: None needed at this time.


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Health Information Management Michelle Welch, RHIT I. Measure Name: Discharge Instructions (Transition of Record)

Measure Description: To improve health outcomes/patient care next level of care providers need to know details of precipitating events immediately preceding hospital admission, the patient’s treatment course during hospitalization including rationale and target symptoms for medications changed, discharge medications and next level of care recommendations (American Association of Community Psychiatrists [AACP], 2001). CMS 482.43 (d) Necessary medical information must be provided not only for patients being transferred, but also for those being discharged home, to make the patient’s physician aware of the outcome of hospital treatment or follow-up care needs. Methodology: Medical Records will review all discharged charts monthly for completion of all elements of the Discharge Instructions (SW Release Plan, Nursing discharge instructions, discharge summary) to assess ongoing compliance with transmittal to follow-up providers within 24 hours of discharge. All discharged charts will be reviewed monthly to ensure a compliance rate of 90% or greater for 4 consecutive months using the clinical pertinence audit tool. The denominator is all discharged charts within the audit month. The numerator will be all discharged charts in compliance within the audit month. Type of Measure: Performance Improvement

Results

Target


Percent of transition of

record transmitted to

next level of care within 24

hours of discharge

4Q2017 89%

95% 95% 95% 95% 95%

Actual 100% 100%

Data Analysis: 1Q2018 is at 100%. This is an increase of 11% above baseline. Action Plan: The above is a new performance indicator for medical records. The plan is to take the above PI to review with staff. Making staff aware of the new performance indicators and the compliance issues will hopefully generate compliance with the above.


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II. Measure Name: Medical Billing Submission Measure Description: To improve the process of medical coding and billing. Medical coding and billing is simply stated as the process of communication between the provider and the insurance company. The billing process begins with the medical care provider/patient visit. The patient’s health record is then updated summarizing the diagnosis, treatment and any pertinent information. The provider then sends a superbill to the reimbursement specialist to enter into the database. Methodology: The reimbursement specialist will receive all provider superbills within seven days. Ward clerks will have the labels on the superbills on Mondays for all patients on the units and provide the providers with them so that they may submit the superbill to Medical Records reimbursement specialist for processing. The denominator will be the total number of superbills that are submitted for the month. The numerator will be the number of superbills that were submitted within seven days. Type of Measure: Performance Improvement

Results

Target


Percent of superbills

received within 7 days of

provider/# of patient

encounter.

4Q2017 75%

90% 90% 90% 90% 90%

Actual 70% 70%

Data Analysis: 1Q2018 fell below the baseline by 5% which is 20% lower than the target. Action Plan: The above is a new performance indicators for medical records. The plan is to take the above PI to review with Medical Staff. Making Med Staff aware of the new performance indicators and the compliance issues will hopefully generate compliance with the above.


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III. Measure Name: Release of Information Measure Description: Coordinate the release of health information to requestors including patients, physicians, other health care providers, and insurance companies within 24 hours or the next business day. Excluded: transition of record Methodology: Medical Records will respond to authorizations to release information within 24 hours or the next business day after receipt. The releases will be reviewed monthly to ensure a compliance rate of 98% or greater using the release of information log. The denominator is the number of releases for the month. The numerator will be all releases that were responded to within the specified time frame. Type of Measure: Quality Assurance

Results

Target


Percent of monthly

discharged records that are

complete.

4Q2017 97%

98% 98% 98% 98% 98%

Actual 98% 98%

Data Analysis: 1Q2018 data increased by 1% compared to the baseline date. Action Plan: The above is a quality assurance indicator for medical records. The plan is to take the above QA to review with medical records staff. Making staff aware of the compliance issues will hopefully generate compliance with the above.


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IV. Measure Name: Medical Record Review Process Measure Description: To ensure uniform construction of all medical records in order to enhance the effectiveness of the contribution to patient care made by complete and concise medical records. Methodology: Medical Records will review all discharged charts monthly for completion, including accuracy and timeliness. All discharged charts will be reviewed monthly to ensure a compliance rate of 98% or greater using the clinical pertinence audit tool. The denominator is all discharged charts within the audit month. The numerator will be all discharged charts in compliance within the audit month. Type of Measure: Quality Assurance

Results

Target


Percent of transition of

record transmitted to

next level of care within 24

hours of discharge

4Q2017 100%

98% 98% 98% 98% 98%

Actual 91% 91%

Data Analysis: 1Q2018 had two out of 23 records that were not complete and accurate within the 30-day time frame resulting in data compliance at 91%. This falls below the baseline as well as target. Action Plan: The above is a quality assurance indicator for medical records. The plan is to take the above QA to review with all staff. Making staff aware of the compliance issues will hopefully generate compliance with the above.


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Infection Control Lisa Tomilson, RN I. Measure Name: Hospital Acquired Infections

Measure 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

Results


Target: 0 HAI

# of HAI per quarter

FY2012 0 HAI

0 HAI 0 HAI

Data Analysis: There were no hospital acquired infections for 1Q2018, and no hospital acquired infection for 4Q2017. Action Plan: Continue to Monitor

FY2016-2018 Hospital Acquired Infections

H. A. Infections FY2016 FY2017 FY2018

1st Quarter H.A.I. Rate 0 1 0

2nd Quarter H.A.I. Rate 0 0

3rd Quarter H.A.I. Rate 1 0

4th Quarter H.A.I. Rate 0 0

Average H.A. Infection Rate 0.25 0.25

Type of Infection

1Q 2016

1Q 2017

1Q 2018

2Q 2016

2Q 2017

2Q 2018

3Q 2016

3Q 2017

3Q 2018

4Q 2016

4Q 2017

4Q 2018

UTI 0 0 0 0 0 0 0 0 0

URI 0 0 0 0 0 0 0 0 0

LRI 0 1 0 0 0 0 0 0 0

Skin 0 0 0 0 0 1 0 0 0

Totals 0 0 0 0 0 1 0 0 0

Infection Rate

0 0.26 0 0 0 0.28 0 0 0


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II. Measure Name: Patient & Family Education on Hand Hygiene/Cough Etiquette

Measure Description: Prior to discharge, a questionnaire will be distributed to each patient that includes the following questions:

D1: I received information on how to stay healthy by washing my hands

D2: I received information on how to cover my cough or sneeze to prevent the spread of illness Type of Measure: Performance Improvement

Results


Target: D1 90%

Quarterly response rate

“agree/strongly agree” for D1 & D2 is set at 90%

2012: D1 response rate: 80%

77% 77%

Target: D2 90%

2012: D2 response rate: 80%

65% 65%

Data Analysis: 1Q2018 response rate for question D1 was 77%, a decrease of 15% from the previous quarter. 1Q2018 response rate for question D2 was 65%, a decrease of 18% from the previous quarter. Number of discharges: 23 Number of questionnaires received: 11. Return rate for FY2018: 48%. Action Plan: For FY2018, the goal remains at 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.


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III. Measure Name: Healthcare Worker (HCW) Hand Hygiene Measure 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

Results

Unit Baseline 1Q2017

1Q2018 2Q2018 3Q2018 4Q2018 YTD

Target: sustained level of compliance

that approaches 90%

HCW hand hygiene

compliance rate per unit per quarter

Knox: 93%

93% 93%

Hamlin: 87%

100% 100%

Chamberlain: 93%

100% 100%

Data Analysis: In 1Q2018, Knox’s compliance rate was 93%, a decrease of 4% from the previous quarter; Hamlin’s compliance rate was 100%, an increase of 7% from the previous quarter; and Chamberlain’s compliance rate was 100%, an increase of 7% from the previous quarter. Action Plan: Continue to monitor HCW hand hygiene compliance per CDC guidelines. Educate staff on how missed opportunities could be corrected.


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IV. Measure Name: Patient Hand Hygiene Measure Description: Patient hand hygiene is being monitored on each unit with a minimum of 4 “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

Results


1Q2018 2Q2018 3Q2018 4Q2018 YTD

Target: sustained level of compliance

that approaches 90%

Pt hand hygiene

acceptance compliance

rate per month

Knox: 83%

83% 93%

Hamlin: 97%

92% 100%

Chamberlain: 63%

63% 100%

Data Analysis: 1Q2018 Knox compliance rate was 83%, 1Q2018 Hamlin compliance rate was 92%, and 1Q2018 Chamberlain compliance rate was 63%. This data collection is new, beginning FY2018. Examples of how hand hygiene compliance failed include: negligence, hand sanitizer unavailable, emergent situations, etc.


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V. Measure Name: Quantiferon Gold testing on all admissions Measure Description: Surveillance data will continue to be gathered on the following Data will be reviewed monthly and reported quarterly. Type of Measure: Quality Assurance

Results


Target: 80%

Quantiferon Gold % per quarter

1Q2018 68%

68% 68%

Data Analysis: 68% of all admissions were tested for TB using the Quantiferon Gold test in 1Q2018. This is data collection is new, beginning FY2018. Action Plan: Continue to monitor adherence rates and educate staff on requirement. VI. Measure Name: Influenza Immunizations

Measure 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

Results

Unit Baseline FY2016 FY2017 FY2018 FY2019 FY2020

Target:

90%

Percent of employees who receive the flu vaccination

FY2015 81%

69% 75%

Data Analysis: For FY2018 the employee flu vaccination compliance rate is unknown at this time, as the clinic is ongoing. Action Plan: Continue to educate staff and promote influenza vaccinations.


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Medical Staff Dr. Michelle Gardner I. Measure Name: Restraint Documentation

Measure Description: Proper documentation is the only way to demonstrate and provide a record that the clinical criteria and assessments for seclusion/restraint have been met. Documentation is critical for patient care/safety, as it validates the care that was provided. Type of Measure: Performance Improvement

Results

Target

Restraints Baseline March 2015

1Q 2018

2Q 2018

3Q 2018

4Q 2018

YTD

Total Restraints 12 31 31

Is order complete? N/A

On order, is the intervention stated in behavioral terms?

100% 99% 99%

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

N/A 87% 87%

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

100% 93% 93%

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

100% 100% 100%

If PA, did PA consult with attending? 100%

Are the details of the event similar on all forms?

100% 98% 98%

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

N/A 97% 97%



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Data Analysis: There were 31 restraints in 1Q2018, with an overall compliance of 96%, six more restraint events than last quarter’s 25, and a 2% increase in compliance from 94%.

• Question “On Form #408 Nursing Seclusion/Restraint Progress Note, Form #470 Nursing Assessment Protocol for Seclusion and Restraint, and Physical Orders do times match for interventions initiated and time of events?” was reintroduced in September due to a failed 6-month audit with an overall quarterly compliance of 87%.

• Question “Are details of events similar on all forms without discrepancies, #408, 409, and Order Sheets?” was reintroduced due to a failed 6-month spot check in July. Overall quarterly compliance for this element is 98%.

Goal: 100% Compliance with Medical Staff Documentation Action Plan: The plan is to continue to monitor compliance with the above data elements, discuss, and address non-compliance in documentation and procedure with medical staff.


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II. Measure Name: Seclusion Documentation Measure Description: Proper documentation is the only way to demonstrate and provide a record that the clinical criteria and assessments for seclusion/restraint have been met. Documentation is critical for patient care/safety, as it validates the care that was provided. Type of Measure: Performance Improvement

Results

Target

Seclusions Baseline (March 2015)

1Q 2018

2Q 2018

3Q 2018

4Q 2018

YTD

Total Seclusions 7 11 11

Is order complete? N/A

On order, is the intervention stated in behavioral terms?

92% 99% 99%

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

N/A 87% 87%

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

100% 93% 93%

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

100% 100% 100%

If PA, did PA consult with attending? 92%

Are the details of the event similar on all forms?

100% 98% 98%

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

N/A 97% 97%



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Data Analysis: 1Q2018 shows an overall compliance of 96% with 11 seclusion events compared to 4Q2017, where there were 12 events and 93% compliance. All seclusion events were locked door. The following questions were previously removed from aggregation; medical staff documentation met the 100% goal for four consecutive months. These questions will be evaluated by spot-check in six months to evaluate and ensure consistent and reliable documentation compliance.

• Are medical staff's S & R progress notes complete? 3Q2017

• Are details of event similar on all forms? 3Q2017

• On order, is the intervention stated in behavioral terms? 3Q2017. Due to a six-month failed audit, this element was reintroduced.

• Does the time of the orders match interventions and times on Nursing forms? 3Q2017. Due to a six-month failed audit, this element was reintroduced.

Goal: 100% Compliance with Medical Staff Documentation Action Plan: The plan is to continue to monitor compliance with the above data elements, discuss, and address non-compliance in documentation and procedure with medical staff.


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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.

Type of Measure: Performance Improvement Methodology: The Medical Director will review data provided by Medical Record monthly for compliance with all elements of a medication order. Ten 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 four 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.


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Data Elements Baseline 4Q2016

1Q2018 2Q2018 3Q2018 4Q2018 YTD

# of Medication orders reviewed

245 274

274

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

100%

Date and time of the order 99%

Medication name 99%

Medication dose 96% 99% 99%

Route of administration 94% 97% 97%

Frequency of administration and/or dosing interval

92% 100% 100%

Indication for use 90% 98% 98%

Authorized prescribers signature and credentials

97% 99% 99%

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

97%



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Data Analysis: Overall compliance for 1Q2018 is 99%, 1% increase from 4Q2017, and equal to 3Q2017. Frequency of administration and/or dosing interval was removed due to meeting four consecutive months of 100% goal in July 2017. This element will continue to be evaluated with a spot check in January 2018. The grayed-out portions are elements which have met goal in previous quarters.

• Medication dose after improvement has been steady at 99% for four quarters.

• Route of administration continues to fluctuate above 95% and finishes 1Q2018 at 97%.

• Frequency of administration and/or dosing interval is 100% for the 1Q2018 and has been removed from aggregation due to meeting goal of four consecutive months of 100%.

• Indication for use is up 2% from last quarter’s up 98%.

• Authorized prescribers signature and credentials is 99%, up 1% from last quarter’s 98%. Action Plan: Information will be disseminated monthly to medical Staff. The Clinical Director will review and address compliance issues with medical staff.


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V. Measure Name: Inpatient psychiatry discharge progress note documented day of discharge or within 24 hours. Measure Description: The inpatient discharge summary is a document clearly encompassing the patient’s full admission, treatment, and discharge; the discharge summary is required to be completed and signed no later than 30 days following discharge. The inpatient psychiatry discharge progress note is designed to be a useful hand-off tool for communication at time of discharge that also increases patient safety by ensuring receiving providers are well-informed to provide appropriate treatment for the patient. Dropped handoffs may cause harm to patients, regardless of clinician skill (Lin, 2014). The inpatient psychiatry discharge progress note completed on the same day, or within 24 hours of discharge decreases the chances of handoff error, miscommunication, and omission of vital information necessary for receiving providers to provide continuity in care. Methodology: Medical staff performance improvement auditing and reporting for this measure is completed via EMR and the medical staff compliance nurse. A monthly report will be run from EMR to gather discharged patient data; each patient’s record will be audited in EMR to assess timeliness of inpatient psychiatry discharge progress note. Type of Measure: Performance Improvement

Results

Target


% of discharge

notes completed within 24

hours

1Q2018 95%

100% 100% 100% 100% 100%

Actual 96%

22/23

96% 22/23

Data Analysis: 1Q2018 goal of 100% was not obtained with an overall compliance of 96%. There was a total of 23 discharges by three providers in the months of July, August and September. The negative element was one Inpatient psychiatry discharge progress note was not completed within 24 hours of discharge. Action Plan: Will continue to monitor compliance with procedure and report any deficiencies to clinical director.


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Nursing Christine Bellatty, RN I. Measure Name: Restraint Audits – Patient Safety

Measure 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 Elements Baseline 4Q2016

1Q 2018

2Q 2018

3Q 2018

4Q 2018

YTD

100%

# of Events 35 31 31

1. Each order obtained within 15 minutes of the intervention?

83%

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

95% 86% 86%

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% 79% 79%

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

97% 98% 98%

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

96%

11. On Form # 407RN 2 Hour Seclusion and Restraint Breaks 2 hour breaks are completed at appropriate intervals and signed by RN?

N/A 100% 100%


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1Q 2018

2Q 2018

3Q 2018

4Q 2018

YTD

100%

12. On Form #407RN 2 Hour Seclusion and Restraint Breaks is time ended for S/R completed and signed by RN

N/A 100% 100%

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?

N/A 100% 100%

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?

N/A 100% 100%

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

99% 100% 100%

16. Is patient debriefing in the chart?

89% 100% 100%

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

88% 91% 91%


Data Analysis: Baseline data compiled August 2015 with updates to Seclusion and Restraint procedure, forms, and audit tool since that time. 1Q2018 showed a decrease from previous quarter, however increased by 7% from baseline; four elements decreased and one element increased. There were 31 restraint events this quarter up from 25 last quarter. There was one mechanical restraint event; with the remaining being physical holds. Numerous restraint events can be contributed to same-patient manual holds over the course of the quarter.

• Knox had one event this quarter, with a rate of 100%.

• Hamlin had two restraint events this quarter, with a compliance rate of 100%.

• Chamberlain had 28 restraint events, including one mechanical restraint event. Overall compliance rate of 84%.


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Nursing documentation was 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 reflected equivalent documentation responsibilities prior to goal accomplishment. Spot checks were completed in July for #9 and August for #5. Both elements were reintroduced due to failing a six-month audit. Both elements were 95%. **“Was legal guardian or agent made aware of time of debriefing?” and “Did legal guardian or agent attend debriefing?” have been removed from aggregate data and are reported via numbers only in monthly reporting- this began with February ’16 reporting.


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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. 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 that events were not captured for data collection.


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II. Measure Name: Seclusion Documentation Measure 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


1Q 2018

2Q 2018

3Q 2018

4Q 2018

YTD

100% Compliance


1. Each order obtained within 15 minutes of the intervention?

91%

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

82%

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%

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

100%

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

88%

11. On Form # 407RN 2 Hour Seclusion and Restraint Breaks 2 hour breaks are completed at appropriate intervals and signed by RN?

84% 75% 75%


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Results


1Q 2018

2Q 2018

3Q 2018

4Q 2018

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%

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%

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% 100% 100%

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

100% 94% 94%

16. Is patient debriefing in the chart?

75% 94% 94%

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

86% 96% 96%


Data Analysis: Baseline data compiled August 2015 with updates to Seclusion and Restraint procedure, forms, and audit tool since that time. 1Q2018 showed an overall compliance of 92%, an increase of 3% from last quarter’s 89%.

• Knox had one seclusion events during the quarter, with a compliance rate of 100%.

• Hamlin had one seclusion event during the quarter with a compliance rate of 100%.


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• Chamberlain had eight seclusion events with a compliance rate of 96%. Nursing documentation met the 100% goal for four consecutive months for the following question. This question will be evaluated by spot-check in six months to evaluate and ensure consistent and reliable documentation compliance. (#12) “On Form #407RN 2 Hour Seclusion and Restraint Breaks is time ended for S/R completed and signed by RN” Nursing documentation met the 100% goal for four consecutive months for the following two questions. These questions will be evaluated by spot-check in six months to evaluate and ensure consistent and reliable documentation compliance. (#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?” (#11) “On Form # 407RN Two Hour Seclusion and Restraint Breaks are two hour breaks are completed at appropriate intervals and signed by RN?” Spot check was completed in August and failed 6-month audit of 75%, therefore this element was reintroduced in September’s reporting. (#15) “Were debriefings DB1 & DB2 completed at appropriate times?” Spot check was completed in August and failed 6-month audit of 88%, therefore this element was reintroduced in September’s reporting. (#16) “Is patient debriefing in the chart?” Spot check was completed in August and failed 6-month audit of 88%, therefore this element was reintroduced in September’s reporting.


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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 2015 that events were not captured for data collection.


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III. 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). 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 • No incomplete initial or location boxes

May 9, 2017, removed requisite area for charge nurse signature, date, and time as it is understood and communicated that the assigned charge nurse for the shift carries responsibility for the assured completion of the form by appropriate staff. 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). November was the first official reporting of this measure; the first quarterly report comprised combined results from November and December, 2016. The goal is to have a combined compliance score of 90% for four consecutive months. The results of the audits will be reported to the IPEC committee quarterly and the Advisory board.

Data

ElementsK1 K2 K3 Total K1 K2 K3 Total K1 K2 K3 Total K1 K2 K3 Total

Total 222B 54 170 55 279 217 324 228 769 159 230 226 615 48 173 213 434

Total

Correct

222B Forms

42 161 42 245 193 302 199 694 145 222 210 577 47 169 212 428

Overall

Compliance78% 95% 76% 88% 89% 93% 87% 90% 91% 96% 93% 94% 98% 98% 100% 99%

Baseline Oct 2016 3Q2017 4Q2017 1Q2018


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Data Analysis: 1Q2018 shows an overall compliance of 99%, this is 5% increase from 4th Quarter’s rate of 94%, up 9% from 3rd Quarter and 11% from baseline’s 88%. By month, overall compliance was: July-98% & August-99%. After four consecutive months of obtaining goals of 90% or above overall compliance, September was audited, but not reported. Monthly auditing will continue and a spot check will be completed in February 2018.

Action Plan: Nursing documentation exceeded goal this quarter. Nursing Administration will continue to address deficiencies in documentation with Clinical Nurse Managers and provide information related to each deficiency for unit follow up.

Reference: [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].


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Outpatient & Forensic Services 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 Elements Baseline FY2016

1Q 2018

2Q 2018

3Q 2018

4Q 2018 YTD

100% Compliance

Total # of Reports Due? 8 4 4

# of Institutional Reports Due?

3 4 4

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

33% 100% 100%

# of Annual Reports Due 5 0 0

Annual Report submitted by December 31, 2015?

80% N/A N/A

Overall Compliance of reports submitted by due date.

63% 100% 100%


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Data Analysis: There were no Institutional Reports required during 1Q2018 as the one petition request was withdrawn by the patient. Although it still does not meet the overall compliance FY2017 had an overall compliance of 73% which was an increase from 63% for FY2016. Action Plan: Continue to track and monitor the completion and submission of the Institutional and Annual reports using a Forensic Timeline Report which will assist in keeping staff notified of upcoming dates. Additional education has been provided to administrative staff about sending hearing notices immediately as it has been determined that the notice of hearing was not sent in a timely manner. Will develop a process for monthly review of institutional reports which will keep them updated and will expedite the finalizing of them when a hearing notice is received. 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 patient services. Type of Measure: Performance Improvement

Results

Target Data elements Baseline FY2016

1Q 2018

2Q 2018

3Q 2018

4Q 2018

YTD

90%

# of Notes 778 455 455

Psychiatric notes entered within 72 hours?

83% 81% 81%

Nursing notes entered within 72 hours?

98% 97% 97%

Social Work notes entered within 72 hours?

88% 91% 91%

Psychology notes entered within 72 hours? 78% 96% 96%



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Data Analysis: Data elements “Psychiatric Notes Entered within 72 hours” increased from 73% to 81% from 4Q2017 to 1Q2018. All other data points decreased slightly as did the overall compliance which when from 97% to 91%. All data points except “psychiatric Notes Entered within 72 hours” remains above the 90% compliance rate goal. Will have continued focus on psychiatric providers increasing their compliance. Action Plan: Continue to audit notes monthly, remind staff of the policy for completing notes and holding monthly meetings during which documentation will be an ongoing discussion. Will have outpatient nurse check notes after clinic days for compliance. Concerns are forwarded to the appropriate supervisor so that they can be addressed individually as part of ongoing competency evaluations.


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III. Measure Name: Timeliness of Initial and Annual Assessment Documentation for Outpatient Services

Measure 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 patient services; therefore, necessary information must be entered and available in the medical record promptly. Type of Measure: Performance Improvement

Results


1Q 2018

2Q 2018

3Q 2018

4Q 2018

YTD

100%

# of Assessments 8 4 4

Psychiatric assessment complete and entered within 30 days?

50% 67% 67%

Nursing assessment complete and entered within 30 days?

88% 100% 100%

Social Work assessment complete and entered within 30 days?

88% 50% 50%



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Data Analysis: There were three annual assessment due for psychiatric, nursing and social work for 1Q2018 and one annual assessment due for dual diagnosis therapy. The data element’s “Psychiatric assessment complete and entered within 30 days” and “Social Work/Dual Diagnosis assessment complete and entered within 30 days” decreased from 100% to 67% and 50% respectively and overall compliance decreased from 100% to 70%. The decrease in social work was partly due to a new employee and miscommunication about entering the completed assessment into Meditech, the evaluation for dual diagnosis occurred as the patient was readmitted to the hospital and therefore was not signed in time. Action Plan: Will continue to audit all assessments monthly, 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. Will also complete weekly checks in meditech when an annual is due to ensure that assessments are being entered successfully. This will remain a performance improvement measure at this time until 100% compliance goal is met again for four consecutive quarters.

IV. Measure Name: Documentation of Supervision hours

Measure Description: Licensing for outpatient services requires minimum supervision hours in order to be licensed to provide services to our patients. The outpatient program manager will review the outpatient supervision log monthly to assess ongoing compliance with the requirement of minimum supervision/consultation of one hour consultation/supervision per month for DDPC outpatient employees licensed to practice independently and 4 hours per month for those employees not licensed to practice independently Type of Measure: Quality Assurance

Results


1Q 2018

2Q 2018

3Q 2018

4Q 2018

YTD

100%

Psychiatric assessment complete and entered within 30 days?

100% 100% 100%

Nursing assessment complete and entered within 30 days?

100% 100% 100%

Social Work assessment complete and entered within 30 days?

100% 100% 100%



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Data Analysis: All data sets were at 100% compliance for 1Q2018. Action Plan: In June of 2015 Outpatient Services began tracking supervision hours to determine whether the supervision process needed to be corrected due to a deficiency noted during the licensing survey. The goal was to have 100% compliance for four consecutive months with the supervision/consultation requirements stated in the DHHS, DLRS Mental Health Agency Licensing Standards SUP.2. and this goal was met. Due to the recent increase in outpatient staff and additional therapy services being offered supervision will be monitored as a quality assurance measure to ensure continued compliance.


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V. Measure Name: Timeliness of amendment of treatment plans to reflect changes in court orders Measure Description: Any change in the court ordered privileges for a NCR outpatient need to be reflected within the treatment plan within a timely manner, seven days, to ensure that the court order is being followed. Updating the treatment plan makes staff aware of any new restrictions or privileges. If the treatment plan is not amended in a timely manner it could cause the patient or staff to violate those privileges which could affect the patient’s ability to obtain increased privileges, modified release, and ultimately release and discharge from the custody of the Commissioner. Type of Measure: Performance Improvement

Results

Target Data elements 1Q2018 2Q2018 3Q2018 4Q2018 YTD

100%

Total # of new court orders? 0 0

# Of treatment plan updates completed within 7 days?

N/A N/A

Overall Compliance N/A N/A

Data Analysis: No new court orders in 1Q2018 for outpatient services. Will also include inpatient services if it is determined that we will follow this guideline in that setting as well. Action Plan: Continued to monitor all new court orders and treatment plans for compliance.


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VI. Measure Name: Timeliness of notification of receipt of court hearing notice. Measure Description: Whenever a NCR patient petitions the court for a change in privileges, a court hearing notice is sent. When the notice is received by administration, the patient’s treatment team and the Director of Forensics need to be notified the same business day as there is required reports which are due within 10 days of receipt of notice of hearing. If notification is not received in a timely manner then the Institutional report could be delayed which could delay State Forensic Services evaluation and could impact the court process. Type of Measure: Performance Improvement

Results

Target Data elements 1Q2018 2Q2018 3Q2018 4Q2018 YTD

100%

Total # of notice of court hearing received? 1 1

# Of notifications received by treatment team on the day the hearing notice was received?

1 1

Overall Compliance 100% 100%

Data Analysis: There was one notice of court hearing for 1Q2018 and it was forwarded to the outpatient team on the day of receipt so compliance was at 100%. Action Plan: Will work with administrative staff to ensure that notifications are forwarded on the day they are received.


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Pharmacy Services Michael Migliore, RPh

I. Measure Name: Medication Management – Controlled Substance Loss Data

Measure Description: Daily and monthly comparison of Pyxis vs CII Safe Transaction Report. Type of Measure: Quality Assurance

Unit Baseline 1Q2018 2Q2018 3Q2018 4Q2018

Target

Rx

4Q2016 8.8/

month

0

# of discrepancies

9.3/ month

Number of CS lost

0 0

Data Analysis: The average number of controlled substance discrepancies per month for 1Q2018 was 4.66. This figure represents the number of discrepancies that occurred and not the number of controlled substance doses lost. Discrepancies typically result from miscounts, all of which have been investigated and reconciled. Action Plan and Comments: Continue to remain vigilant and to educate staff on proper automated dispensing cabinet procedures to avoid the creation of discrepancies. The Pharmacy department will continue to monitor and track and trend inconsistencies.


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II. Measure Name: Fiscal Accountability

Measure Description: Tracking of Dispensed Discharged Prescriptions Type of Measure: Quality Assurance


Target

All

FY2016 $1145.77 for 101 meds

$11.36/Rx

0 0

Actual $4.44/ 3 Rxs

$4.44/ 3 Rxs

$/Rx $1.48 $1.48

Data Analysis: During 1Q2018, a total of three discharge prescriptions were dispensed totaling $4.44 averaging out to $1.48 per prescription. Action Plan and Comments: The pharmacy department will continue to monitor and reduce discharge medication costs. In addition to reporting a lower number of discharge Rx’s for 1Q2018 the cost of a first quarter prescription was $1.48, a $9.49 decrease from the baseline 2017 figure.


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III. Measure Name: Invalid Orders Measure Description: Incomplete/Invalid Orders Type of Measure: Performance Improvement

Background: With a zero tolerance policy for invalid 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. Receiving an invalid order by the pharmacist requires documentation, copying and returning the invalid order to the prescriber for remediation as well as contacting and informing the unit of the invalid order.

Data Analysis: For 1Q2018, the total number of invalid orders reported was zero. Keeping providers informed, and reporting this information at the monthly Pharmacy and Therapeutics Committee meeting has resulted in favorable reportable invalid/incomplete order metrics. Action Plan: Tracking incomplete orders will continue until the implementation of electronic health records scheduled to be implemented in the upcoming year. The system will contain hard stops preventing providers to proceed to initiate an order that is not complete.


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IV. Measure Name: Polyantipsychotic Therapy (PAPT) Therapy

Measure 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 three 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: Performance Improvement

Results

% Of Census 1Q2018 2Q2018 3Q2018 4Q2018 YTD

On 1 Antipsychotic 53 53

On 2 Antipsychotic 30 30

On >3 Antipsychotic 4 4

Results


Failed 3> Monotherapy 33 33

Clozapine Augmentation 13 13

Tapering to Monotherapy 53 53

Results


With Appropriate Justification 100 100

Without Appropriate Justification 0 0

Data Analysis: All medication profiles in the hospital are reviewed on admission and in each month of the quarter for antipsychotic medication orders. Attending psychiatrists are required to complete a Polyantipsychotic Therapy Justification Form when a patient is prescribed more than one antipsychotic.

Action Plan: Pharmacy will continue to monitor for and alert prescribers to provide appropriate justification for polyantipsychotic therapy.


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V. Measure Name: Metabolic Monitoring Measure 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

Results


Target

Complete/ Up-

to-date Metabolic

Parameters

73%

75% 75% 75% 75% 75%

Actual

66% 66%

Data Analysis: The pharmacy collects data around specified parameters to monitor the metabolic status of all patients in the hospital who are receiving atypical antipsychotics during the quarter. Data elements collected are BMI (body mass index), blood pressure, fasting blood glucose, hemoglobin A1c, HDL cholesterol, and triglycerides. Action Plan: We will monitor the stated parameters for metabolic syndrome in patients prescribed second generation/atypical antipsychotic therapy. The patient’s right to refuse assessment (weight, blood pressure and lab work) has been identified as a contributing factor to not being able to fully assess metabolic status. We will continue to work with the medical staff to identify patients whose metabolic profiles are incomplete/inconclusive, in order that we may more accurately monitor the population for the hallmark parameters. Comments: In patients receiving antihypertensive medications, we conclude that the patient’s untreated blood pressure is greater than 130/85. In patients receiving insulin or oral/injectable antihyperglycemics, we conclude that the patient’s fasting blood glucose >110. In patients receiving statins or other cholesterol-modifying therapy we conclude dyslipidemia.

1Q2018

Patients with complete/up-to-date parameters 25/38

Patients with incomplete/outdated parameters 13/38

Patients who meet criteria for metabolic syndrome 15

Patients who do not meet criteria for metabolic syndrome

10

Patients who cannot be classified at this time 13


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VI. Measure Name: Veriform Medication Room Audits Measure Description: Quarterly Completion by Unit Audits Type of Measure: Quality Assurance

Results


Target

All FY2017 100%

100% 100% 100% 100% 100%

Actual 100% 100%

Methodology: Monthly, the Pharmacy Department performs comprehensive inspections of medication rooms, central supply areas, and the medical clinic. Over 44 criteria are monitored in the audits utilizing Veriform software. Data Analysis: The medication room audits have been concluded for 1Q2018 without completion deficiencies. Pharmacy continues to strive for audits that are 100% complete Action Plan: The Pharmacy Department will continue to send reminders early in the process to ensure that completion, compliance, verification and reporting is performed in a timely fashion. Comments: Continuous monitoring of the medication room audits and approval by the responsible individuals has again provided satisfactory results for this quarter.


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VII. Measure Name: Medication Dispensing Process

Measure


Goal 1Q2018 2Q2018 3Q2018 4Q2018

Controlled Substance Loss Data:

Daily Pyxis-CII Safe Compare Report. All 0%

Target: Actual:

0% 0%

Monthly CII Safe Vendor Receipt Report. Rx 0

Target: Actual:

0 0

Monthly Pyxis Unresolved Controlled Drug Discrepancies.

All 0/

month Target: Actual:

0 14

(4.66/mo)

Measures of drug reactions, adverse drug events and other management data.

Rx 1.25 Target: Actual:

0 0

Resource Documentation Reports of Clinical Interventions.

Rx 397 Target: Actual:

100% 32

Psychiatric Emergency Process: Monthly audit of all psych emergencies measures against 8 criteria.

All 100% Target: Actual:

100% 100%

Operational Audit: Monthly audit of 8 operational indicators from CPS contract. *

Rx 100% Target: Actual:

100% 88%

* a corrective action plan was provided and initiated immediately


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Risk Management Heather Racine RN, BSN I. Measure Name: Allegations of Abuse, Neglect, and Exploitation

Measure Description: All patients have the right to be free from abuse, neglect or exploitation, as well as the fear of being abused, neglected or exploited. Allegations or information indicating that abuse, neglect, or exploitation may have occurred must be thoroughly and promptly investigated with appropriate follow-up action taken. Type of Measure: Performance Improvement Methodology: The numerator will be all allegations for the quarter that were found to be promptly investigated with appropriate follow-up action taken. The denominator will be all allegations for the quarter.

Results


Target: 100%

compliance with

allegation process

# of allegations per quarter

1Q2018 100% 14/14

100% 14/14

100% 14/14

Data Analysis: There were 14 allegations of abuse reported for 1Q2018. All 14 allegations reported were thoroughly and promptly investigated with appropriate follow-up action taken. The compliance rate is 100%.

Action Plan: Will continue to thoroughly and promptly investigate all allegations of abuse, neglect, and exploitation and follow-up with appropriate action.


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Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Number of Allegations 8 2 4

Number of Allegations PromptlyInvestigated

8 2 4

Compliance Rate % 100% 100% 100% 0% 0% 0% 0% 0% 0% 0% 0% 0%

02468

10

# o

f A

llega

tio

ns

FY2018 Allegations of Abuse, Neglect, and Exploitation Reporting

1Q 2Q 3Q 4Q

Number of Allegations 14 0 0 0

Number of Allegations PromptlyInvestigated

14 0 0 0

Compliance Rate % 100% 0% 0% 0%

02468

10121416

# o

f A

llega

tio

ns

FY2018 Quarterly Compliance with Reporting Allegations of Abuse, Neglect, and Exploitation


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II. Measure Name: Incident Reports

Measure Description: As a learning organization DDPC realize that every patient safety event (from minor events to events that cause major harm to patients) must be reported. When patient safety events are continuously reported, experts within DDPC can define the problem, identify solutions, achieve sustainable results, and disseminate the changes or lessons learned to the rest of the hospital. As a learning organization, DDPC provides staff with information regarding improvements based on reported concerns and this helps foster trust that encourages further reporting. Type of Measure: Quality Assurance Methodology: All patient safety events for the quarter that were not reported via an incident report. Monitoring for unreported patient safety events will occur via morning report, Superintendent Dashboard, and rounds.

Results


Target: 100%

compliance

# of incident reports not

reported per quarter

1Q2018 7

7 7

Data Analysis: There were seven incidences that were not reported via an incident report for 1Q2018. Action Plan: Will continue to monitor for unreported patient safety events.


83


84

Social Services Tammy Cooper, LCSW I. Measure Name: 30 Day Readmissions Modified Root Cause Analyses

Measure 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. Having identified factors that contribute to preventable readmissions, hospitals are expected to revise their discharge planning and related processes to address these factors.

Type of Measure: Quality Assurance

Results


Target

FY2017 100%

100% 100% 100% 100% 100%

Actual

100% 100%

Data Analysis: There were two 30 day readmissions in 1Q2018. One readmission was due to a patient needing medical hospitalization and was transferred to a medical hospital. She was discharged to the hospital on 7/19/17 and admitted back to DDPC on 7/25/17. Per social work discharge planning procedure 5-1: If the patient is not readmitted in the allowed time (72 hours), then the discharge order becomes permanent and a Release Plan will be required. The second readmission was on 7/5/17 when a patient refused to continue medication compliance after release back to Penobscot County Jail on 6/9/17. The medication prescribed was on the jail formulary and the only interruption within this discharge was reported by the jail administrator that the administration and medical departments were not notified that this inmate was returning. An internal review was done regarding this situation. It was established that contact was made by the Forensic Liaison with Penobscot County Jail Transport Department. That Transport Department did not notify administration or medical departments that they were doing so. Nothing was found stating that there was clinical hand-off by the hospital to the jail. Medications were given to corrections staff, but not passed on directly to the medical department at the jail. Action Plan: A procedure for Forensic Discharge Planning will be developed to address forensic patients returning to jail. Educating the teams that the Forensic Liaison is there to help facilitate discharge planning needs with jail departments as needed.


85

Results

Target Data elements Baseline 4Q2016

1Q 2018

2Q 2018

3Q 2018

4Q 2018

YTD

Readmissions within 30 days of discharge

2 2 2

Progressive Treatment Plan (PTP) readmissions within 30 days

1 2 2

45 day root cause analyses due within the quarter

2 2 2

100% Compliance with completion of a 45 day modified root cause analysis for all 30 day readmissions

100% 100% 100%


86

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


1Q 2018

2Q 2018

3Q 2018

4Q 2018

YTD

100%


Unit Staff compliant with addressing grievance?

89% 86% 86%

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

63% 73% 73%

*Nursing Supervisor compliant with addressing grievance within 4 hours?

86% 84% 84%

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

61% 88% 88%

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

100% 94% 94%

*Overall Compliance of Nursing Supervisor and Social Worker addressing grievance

80% 85% 85%


87

• 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 four hours

• Element 4: Nurse Supervisor completed form correctly and forwarded to Social Worker

• Element 5: Social Worker addressed grievance within five days or more than five days if extension is requested

• Element 6: Overall Compliance of Nursing Supervisor and Social Worker Addressing Grievance Data Analysis: All data elements decreased from 4Q2017 to 1Q2018. Overall compliance for Nursing Supervisor and Social Worker addressing grievance decreased from 98% to 85%. Action Plan: Working on finalization of new complaint and grievance form which are more clearly marked where documentation and signatures are needed. With revision of grievance policy will seek 24-hour response time instead of four hours by CNM or nurse supervisor to allow staff time to gather information and meet with patients during the day when they are not available during the day. Further training by patient advocates and management for unit staff would be beneficial as well. Continue to provide feedback to Director of Nursing and supervisors when forms are not completed correctly.


88

Staff Education and Development Jenny Bamford-Perkins, MSN, RN I. Measure Name: Mandatory Staff Education

Measure 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 above and the table below reflect Staff Education requirements through 1Q2018. The goal is for 100% compliance by the staff education year end in the 2Q of each fiscal year.


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Learning Packets 3Q2017 4Q2017 1Q2018 2Q2018

AMD 52%

BOUND 98% 100% 100%

BTUCS 98% 100% 100%

CAUTI's 95%

CNA 76%

COAG 93%

CPR 100% 100% 100%

CUSHION 94% 94%

Diversity 88% 100% 100%

DM Risk 99% 99%

DYINGPT 99%

EBOLA 100% 100%

EOC 98% 100% 100%

ETHICS 82% 99% 100%

EVAC CHAIR 93%

FALLS 82% 99% 100%

GLUCOCE 100%

HOCOMM 97% 100% 99%

HYTERA 77% 99% 100%

IC-ILI 77% 99% 100%

ILP 99%

INFCON 77% 99% 93%

LIFESP 88% 100% 99%

MANDT/SRST 100% 100% 100%

MDRO 88% 99% 100%

MEDSFYQ 99%

MOBDEV 88% 100% 94%

NPSG-L 88% 100% 100%

NPSG-MH 83% 100% 100%

PAIN RN/MD 77% 99% 100%

PI/SE Q 84% 100% 99%

PWERST 82% 97% 100%

REPORTING POLICIES 82% 99% 99%

RN EXAM 100%

S/R LP 84% 100% 74%

TJCREP 84% 99% 100%


90

Action Plan: Staff Education will complete monthly audits, send monthly e-mails to staff that have not completed their learning packets, send a notice to supervisors by the 3Q of the calendar year to address their staff that are out of compliance, and alert the superintendent of employees out of compliance. II. Measure Name: RN/MHW Additional Continuing Education

Measure Description: Both Registered Nurses and Mental Health Workers are required to have additional continuing education specific to their discipline. Methodology: The numerator will be the number of RN/MHW’s that completed their additional continuing education requirements for the quarter and the denominator will be the total number of RN/MHW’s for the quarter. The goal is to have 100% compliance of additional continuing education requirements by the staff education year end in the 2Q of each fiscal year.

Results


3Q2017 4Q2017 1Q2018 2Q2018

Target % Compliance 100% 100%

Actual

% RNs completed

62% 62%

% MHWs completed

66% 66%

Data Analysis: This is a new measure starting 1Q2018. The table above reflects Staff Education requirements for Nurses and Mental Health Workers for 1Q2018. The goal is for 100% compliance by the staff education year end in the 2Q of each fiscal year Action Plan: Staff Education has created multiple learning packets specific to each discipline which was released in September 2017. Staff Education will complete monthly audits, send monthly e-mails to staff that have not completed their learning packets, send a notice to supervisors by the 3Q of the calendar year to address their staff that are out of compliance, and alert the superintendent of employees out of compliance.


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III. Measure Name: Direct Care Staff Skills Fair Measure Description: All direct care staff members are required to attend Staff Education’s Skills Fair. Methodology: The numerator will be the number of RN/MHW’s that attended the Direct Care Staff Skills Fair for the quarter and the denominator will be the total number of RN/MHW’s for the quarter. The goal is to have 100% compliance of Skills Fair attendance by the Staff Education year end in the 2Q of each fiscal year.

Results

Unit Baseline 3Q2017 4Q2017 1Q2018 2Q2018

Target % Attendance

1Q2018 71%

100%

Actual 71%

Data Analysis: This is a new measure, and the table above reflects staff education requirements for 1Q2018. The goal is for 100% compliance by the staff education year end in the 2Q of each fiscal year. Action Plan: Staff Education will offer monthly Skills Fairs to all direct care staff. Staff Education will send monthly e-mails to staff notifying them of the scheduled dates and times the Skills Fair will be offered. Staff Education will send a notice to supervisors by the 3Q of the calendar year to address their staff that are out of compliance, and alert the superintendent of employees out of compliance.


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Therapeutic Services Lisa J. Hall, OTR/L I. Measure Name: Provider Direct Patient Contact

Measure 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. Staff are expected to spend at least 45% of their available time interacting with patients. Numerator: number of hours spent in direct contact with patients Denominator: number of hours available to spend in direct contact with patients Type of Measure: Quality Assurance

Results


Target

Percent of

staff meeting

expectation

Dec. 2017 50%

(11/22)

90% 90% 90% 90% 90%

Actual

94% 17/18

94%

17/18

Data Analysis: Out of 18 Therapeutic Staff members who submitted direct care statistics 17 met or exceeded the department goal of 45% meaning 94% of the department staff are in compliance with this QA measure. One staff member did not submit data for this time period. The one staff member who did not meet the target has a student sharing in the caseload. Action Plan: Continue with monthly monitoring for next quarter.


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II. Measure Name: Timely Assessment / Improving Health Outcomes Measure 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

Data Analysis: One hundred percent of psychological testing were completed on time, an improvement over previous quarters. Out of nine substance abuse evaluation requests received, three (33%) were completed on time which is a decrease in timeliness of evaluations overall. Action Plan: Psychology positions are vacant as of August 2017. Will continue to monitor when the position(s) are filled. Timeliness of substance abuse evaluations will continue to be monitored for FY2018. In an effort to prioritize timely evaluation, options for documentation are being explored, staff work schedules and group responsibilities are changing effective November 2017. In addition, recruitment efforts are underway to hire additional staff trained in substance abuse evaluation and treatment.


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A. 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


Target

Percent of

assessments completed on

time

41%

90% 90%

Actual 33% 3/9

33% 3/9

B. 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.

Results


Target

Percent of

assessments completed on

time.

58%

90% 90%

Actual

100% 3/3

100% 3/3


95

II. Measure Name: Provision of Therapeutic Services Measure Description: In order to receive active treatment at a frequency and intensity to provide efficient treatment and discharge planning, the goal is for 75% of the patient population to engage in 14 hours of active treatment provided by the therapeutic services department each week. Of the 24 charts audited each month (72 per quarter), the goal is for 75% of the charts audited to reflect at least 14 hours of therapeutic services per week. The hours of treatment, per patient, will be rounded to the nearest whole number. Numerator – Number of charts containing 14 or more hours of documented treatment by therapeutic services personnel. Denominator – Total number of charts audited. Type of Measure: Performance Improvement

Results


Target 14 hours of

documented treatment per chart

June 2017 25% 6/24

45% 55% 65% 75% 45%

Actual 14%

10/72

14% 10/72

Data Analysis: 31 (43%) of the 72 charts audited contained less than five hours of documented treatment provided by therapeutic services within the week. An additional 15% of charts were close to meeting the standard though still below the 45% target. Re-assigning OT, RT, and Habilitation Aide’s to the units proved to be unsuccessful increasing patient engagement in treatment. Action Plan:

• October 1st, 2017 - Expect weekly/monthly progress notes to re-assess needs for treatment.

• November 5th, 2017 – Re-assign staff with focus on unit and individual treatment instead of groups participation.


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IV. Measure Name: Patient Attendance in Recommended Group Treatment Measure Description: Patients and treatment teams will select groups that are targeted toward attaining established treatment goals. Ensuring patients attend groups that are in their treatment plan is part of active treatment. And will be monitored for overall improvement. Type of Measure: Performance Improvement

Results


Target

Instance of

possible attendance

March 2017 24%

40% 55% 70% 85% 63%

Actual

32% 32%

Data Analysis: Trending slightly upward over the course of the quarter and an eight percent increase over baseline data collected in March, 2017. Action Plan: Changing groups so that only one is offered at a time and individual disciplines are responsible for enrolling patients according to stated goals on patient treatment plans. Will implement in November 2017.

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