Liberty Healthcare Psychiatric Nurse Practitioner Dr. Michelle Gardner Clinical Director All indicators met standards. Locum Tenens Psychiatry Dr. Michelle Gardner Clinical Director Contract not utilized during timeframe. MD-IT Transcription Michelle Welch Medical Records Administrator All indicators met standards. Northeast Cardiology Associates (NECA) Dr. Michelle Gardner Clinical Director All indicators met standards. Norris, Inc. Mark Faulkner Acting Director of Facilities All indicators met standards. Otis Elevator Mark Faulkner Acting Director of Facilities All indicators met standards. Penobscot Community Health Care (PCHC) Dr. Michelle Gardner Clinical Director Indicator met standards. Project Staffing Carol Davis Business Manager All indicators met or exceeded standards. Securitas Mark Faulkner Acting Director of Facilities All indicators met or exceeded standards. The Healing Staff Dr. Michelle Gardner Clinical Director Contract not utilized during timeframe. UniFirst Mark Faulkner Acting Director of Facilities All indicators met standards. Vista Staffing Dr. Michelle Gardner Clinical Director Contract not utilized during timeframe. WBRC Architects Engineers Mark Faulkner Acting Director of Facilities All indicators met standards. Worldwide Travel Staffing Carolyn Dimek Director of Nursing All indicators met standards. 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)
Measure Unit Baseline 4Q2016 Goal 1Q2017 2Q2017 3Q2017 4Q2017 Controlled Substance Loss Data: Pyxis-CII Safe Compare Report. All 0% Target: Actual: 0% 0% 0% 0% 0% Monthly CII Safe Vendor Receipt Report. Rx 0 Target: Actual: 0 0 0 0 0 Monthly Pyxis Unresolved Controlled Drug Discrepancies. All 0/ month Target: Actual: 0 0 0 0 0 Medication Management Monitoring: Measures of drug reactions, adverse drug events and other management data. Rx 2 Target: Actual: 0 0 0 0 0 Resource Documentation Reports of Clinical Interventions. Rx 397 Actual: 867 Consumer Surveys TJC PI.01.01.01 EP16: The hospital collects data on the following: Patient perception of the safety and quality of care, treatment, and services. In order to gain a perspective on the quality of care provided to our patients from the patient’s perspective, Dorothea Dix Psychiatric Center conducts two patient surveys; the Care Transition Measures Survey and the Inpatient Customer Survey. Care Transition Measures Survey The Care Transition Measures Survey (CTM-3) is a three question survey that is designed to ascertain the degree of patient understanding of and satisfaction with the discharge planning and preparation process. Dorothea Dix conducts a telephone poll of discharged patients approximate one to two weeks after discharge. This provides an opportunity to make a connection with the patients as they transition into the community setting and, on occasion, has provided the discharged patient with a support mechanism or safety net on those few
Infection Control Heather Brock, 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 Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD Target: 0 HAI # of HAI per quarter FY 2012 0 HAI 1 HAI 1 HAI Data Analysis: There were one hospital acquired infections for 1st quarter FY2017, and 0 hospital acquired infection for 4th quarter FY2016. H. A. Infections FY 2015 FY 2016 FY 2017 1st Quarter H.A.I. Rate 0 0 1 2nd Quarter H.A.I. Rate 0 0 3rd Quarter H.A.I. Rate 0 1 4th Quarter H.A.I. Rate 0 0 Average H.A. Infection Rate 0 0.25 1 FY 2014-2016 Hospital Acquired Infections Type of Infection 1Q 2015 1Q 2016 1Q 2017 2Q 2015 2Q 2016 2Q 2017 3Q 2015 3Q 2016 3Q 2017 4Q 2015 4Q 2016 4Q 2017 UTI 0 0 0 0 0 0 0 0 0 URI 0 0 0 0 0 0 0 0 0 LRI 0 0 1 0 0 0 0 0 0 Skin 0 0 0 0 0 0 1 0 0 Totals 0 0 0 0 0 0 1 0 0 Infection Rate 0 0 0.26 0 0 0 0.28 0 0
Infection Rate per 1000 patient days: Total number of infections per unit x 1000 = % number of inpatient days 1st Quarter 2015 = 3256 1st Quarter 2016 = 3361 1st Quarter 2017=3889 2nd Quarter 2015 = 3550 2nd Quarter 2016 = 3508 2nd Quarter 2017= 3rd Quarter 2015 = 3453 3rd Quarter 2016 = 3587 3rd Quarter 2017= 4th Quarter 2015 = 3422 4th Quarter 2016 =3584 4th Quarter 2017= II. Measure Name: Patient & Family Education on Hand Hygiene/Cough 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 Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD Target: D1 90% Quarterly response rate “agree/strongly agree” for D1 & D2 is set at 90% 2012: D1 response rate: 80% 86% 86% Target: D2 90% 2012: D2 response rate: 80% 86% 86% Data Analysis: First quarter response rate for question D1 was 86%, a decrease of 7% from the previous quarter. First quarter response rate for question D2 was 86%, a decrease of 4% from the previous quarter. Action Plan: For FY2017, the goal has been increased to 90% compliance rate.
Results Unit Baseline FY 2016 FY 2017 FY 2018 FY 2019 FY 2020 Target: 90% Percent of employees who receive the flu vaccination FY 2015 81% 69% Action Plan: Continue to educate and promote influenza vaccinations. Comments: DDPC is currently hosting its annual Flu Clinic for 2016-2017. Medical Staff Dr. Michelle Gardner I. Measure Name: Restraint 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 2015) 1Q 2017 2Q 2017 3Q 2017 4Q 2017 YTD 2017 Total Restraints 12 39 39 Is order complete? N/A 89% 89% On order, is the intervention stated in behavioral terms? 100% 87% 87% 100% Does the time of the orders match interventions and times on Nursing forms? N/A 94% 94% Is Medical Staff Seclusion and Restraint Progress Note complete (both sides)? 100% 65% 65% Is the time of the 1 hour face to face within an hour of the event? 100% 100% 100%
Is Medical Staff Seclusion and Restraint Progress Note complete (both sides)? 100% 44% 44% Is the time of the 1 hour face to face within an hour of the event? 100% 100% 100% If PA, did PA consult with attending? 92% 100% 100% Are the details of the similar on all forms? 100% 100% 100% Did the medical provider participate in the Seclusion and Restraint treatment plan review? N/A 100% 100% Overall Compliance 96% 84% 84% Goal: 100% Compliance with Medical Staff Documentation Data Analysis: There were 12 seclusions in the 1st quarter. The overall compliance rate decreased 12%: from 96% in 4th quarter FY2016 to 84% 1st quarter FY2017. Action Plan: The plan moving forward is to continue to monitor compliance with the above data elements and to discuss and address non-compliance with the medical staff. III. Measure Name: All elements of a medication order are complete. Measure Description: To promote safe medication ordering by defining the required elements of a complete medication order. Type of Measure: Performance Improvement Data Elements Baseline 4Q2016 1Q2017 2Q2017 3Q2017 4Q2017 Total Compliance # of Medication orders reviewed 245 258 258 Medication order sheet has patient name, DOB and hospital number ID (2 patient identifiers)? 100% 100% 100% Date and time of the order 99% 99% 99% Medication name 99% 100% 100%
Medication dose 96% 97% 97% Route of administration 94% 97% 97% Frequency of administration and/or dosing interval 92% 98% 98% Indication for use 90% 96% 96% Authorized prescribers signature and credentials 97% 98% 98% Telephone orders completed, signed, and timed w/in 72 hr. 97% 100% 100% Overall Compliance 93% 98% 98% Data Analysis: Six data elements were found to be below the established goals of 100% for the 1st quarter; however, all have shown an improvement from 4th quarter FY2016. The data elements remain above the threshold of 90% compliance. Action Plan: Continue to monitor. Nursing Janet Babcock, 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 4Q2016 1Q 2017 2Q 2017 3Q 2017 4Q 2017 YTD 100% # of Events 35 39 39
14. On Form #407 Seclusion & Restraint Monitoring and Assessment did each staff member that initialed 15 minute checks complete last page of form with signature and title? 61% 68% 68% 15. Were debriefings DB1 & DB2 completed at appropriate times? 100% 83% 83% 16. Is patient debriefing in the chart? 75% 100% 100% 19. Was Form # 470 TX Focused Treatment Plan Review completed within 24 hours? 86% 83% 83% Overall Compliance 85% 89% 89% Data Analysis: First quarter FY2017 comparison to fourth quarter FY2016 (new baseline) shows 89%; a 4% increase; 6 elements increased, 4 elements decreased, and 2 stayed the same. There were 10 total seclusion events this quarter with totals of July: Knox 1, Hamlin 1, Chamberlain 1, for a total of 3; August: Knox 0, Hamlin 0, and Chamberlain 2, for a total of 2; September: Knox 4, Hamlin 1, Chamberlain 0, for a total of 5. Unit totals for 1Q2017 overall compliance are: Know 83% with 5 events, Hamlin 96% with 2 events, and Chamberlain 90% with 3 events. Action Plan: Nursing staff remains below goal and will continue to audit the documentation of patient seclusions on a monthly basis and re-evaluate quarterly and yearly. Nursing
Results Target Data elements Baseline FY 2016 1Q 2017 2Q 2017 3Q 2016 4Q 2017 YTD 100% # of Events 46 13 13 Unit Staff compliant with addressing grievance? 89% 92% 92% Unit Staff completed form correctly (boxes checked, dated/timed, all signatures completed, Nurse Supervisor notified)? 63% 38% 38% *Nursing Supervisor compliant with addressing grievance within 4 hours? 86% 92% 92% Nurse Supervisor completed form correctly (boxes checked, dated/timed, all signatures completed, forwarded to Social Worker)? 61% 31% 31% *Social Worker compliant with addressing grievance within 5 days or within 5 more days if extension is requested? 100% 100% 100% *Overall Compliance of Nursing Supervisor and Social Worker addressing grievance 93% 96% 96% Element 1: Unit compliant with addressing grievance Element 2: Unit Staff completed form correctly and notified Nurse Supervisor Element 3: Nurse Supervisor addressed grievance within 4 hours Element 4: Nurse Supervisor completed form correctly and forwarded to Social Worker Element 5: Social Worker addressed grievance within 5 days or more than 5 days if extension is requested Element 6: Overall Compliance of Nursing Supervisor and Social Worker Addressing Grievance
A. Measure Name: Direct Patient Contact - Occupational Therapy Results Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD Target Percent of time in direct patient contact. 36% March 2015 50% 50% 50% 50% 50% Actual 48% 48% B. Measure Name: Direct Patient Contact - Therapeutic Recreation Results Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD Target Percent of time spent in direct patient contact. 53% March 2015 50% 50% 50% 50% 50% Actual 55% 55% C. Measure Name: Direct Patient Contact - Clinical Services Results Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD Target Percent of time spent in direct patient contact. 35% March 2015 50% 50% 50% 50% 50% Actual 41% 41% D. Measure Name: Direct Patient Contact- Ancillary Services (Dietician, Chaplain, Peer Support, Treatment Habilitation Aide)