SBAR Acronym for a of concise communications first developed by the US Navy Submarine Command. S = Situation, B = Background, A = Assessment, R = Recommendation SD Standard Deviation – a measure of data variability. Staff Development. Seclusion, Locked Patient is placed in a secured room with the door locked. Seclusion, Open Patient is placed in a room and instructed not to leave the room. SRC Single Room Care (seclusion) STAGE III 60 Day Forensic Evaluation TJC The Commission (formerly JCAHO, Joint Commission on Accreditation of Healthcare Organizations) URI Upper Respiratory Infection UTI Urinary Tract Infection VOL Voluntary – Self Voluntary – Others (Guardian) ii Introduction The Riverview Psychiatric Center Quarterly Report on Organizational Performance Excellence has been created to highlight the efforts of the hospital and its staff members to provide evidence of a commitment to patient recovery, safety in culture and practices, and fiscal accountability. The report is structured to reflect a philosophy and contemporary practices in addressing overall organizational performance in a systems improvement approach instead of a purely compliance approach. The structure of the report also reflects a focus on meaningful measures of organizational process improvement while maintaining measures of compliance that are mandated through regulatory and legal standards. The methods of reporting are driven by a nationally accepted focused approach that seeks out areas for improvement that were clearly identified as performance priorities. The American Society for Quality, National Quality Forum, Baldrige National Quality Program and the National Patient Safety Foundation all recommend a systems-based approach where organizational improvement activities are focused on strategic priorities rather than compliance standards. There are three major sections that make up this report: The first section reflects compliance factors related to the Consent Decree and includes those performance measures described in the Order Adopting Compliance Standards dated October 29, 2007. Comparison data is not always available for the last month in the quarter and is included in the next report. OTHER
minimally one time per week. The Patient Discharge Plan Report will be reviewed/updated minimally one time per week by the Director of Social Services. 100% 11/11 100% 10/10 100% 12/12 100% 12/12 3. The Patient Discharge Plan Report will be sent out weekly as indicated in the approved court plan. 100% 11/11 90% 9/10 92% 11/12 83% 10/12 Each week the Social Work team and Director will meet and discuss current housing options provided by the respective regions and prioritize referrals. 100% 11/11 100% 10/10 100% 12/12 100% 12/12 1Q2016: 3. On two occasions the report was not sent out electronically during a week, it was presented at the Wednesday housing meeting due to computer issues and inaccurate information in the report. CONSENT DECREE V22) The Department demonstrates that 95% of the annual reports for forensic patients are submitted to the Commissioner and forwarded to the court on time. Indicators 2Q2015 3Q2015 4Q2015 1Q2016 Institutional Reports will be completed, reviewed internally, and delivered to the court within 10 business days of request. 0% 0/5 0% 0/8 66% 2/3 66% 2/3 The assigned CCM will review the new order with the patient and document the meeting in a progress note or treatment team note. 100% 3/3 100% 2/2 100% 3/3 100% 3/3 Annual Reports (due in December) to the Commissioner for all inpatient NCR patients are submitted annually 100% 25/25 N/A N/A N/A 1Q2016: 1. Institutional Reports were done. Two of the reports were completed in the 10 business day timeframe. We continue to monitor the process to track the reports in the quarter to get improved results for completion.
Quality Improvement Measures from “Response to the Recommendations from the Report by Elizabeth Jones, Consultant” Approved by the Superior Court on February 27, 2015 Leadership met on Friday, 6th to review the corrective action steps outlined in the hospital’s response. Recommendation Quality Improvement Measure Actions Taken During the Quarter Prior to his/her treatment team meeting, the class members should be provided the opportunity to meet with a peer specialist in order to prepare for the discussion and to clearly outline any preferences for treatment or discharge planning. approaches to treatment, including employment, should be consistently explored with and offered to class member, despite disinterest or refusal at the time of admission. Treatment Team Coordinators will document all patient engagement in preparation for Treatment Team meetings. The chart audit form used by Treatment Team Coordinators/Auditors will be updated by Medical Records to reflect which patients received pre-treatment team meeting engagement. Treatment Team Coordinators developed & use an audit tool on each record as it is reviewed / revised the day of the team meeting. TTCs handout to the patient, the ‘Your Input is Essential” form 2-3 days prior to the meeting and offer to assist the patient to complete the form (if needed) prior to the meeting. The form is attached to the treatment plan. If patient refuses to complete the from, this is noted on the form and signed by the staff. Riverview's leadership should take immediate steps to ensure that the principles of the Recovery model are clearly defined, articulated, and supported throughout each of the four units. 100% of patient records will include documentation of the patient's input into their individualized treatment plan and that the input was used during the Treatment Team meeting. Staff orientation has increased focus on the principles of recovery. As part of this effort staff are encouraged to support patients with making their needs, goals and life expectations made know. Where appropriate and in consistency with the TP, the patients’ comments are incorporated into treatment planning activities. CONSENT DECREE Recommendation Quality Improvement Measure Actions Taken During the Quarter Riverview's clinical leadership should work with nursing and Mental Health Worker staff to The list of case conferences and Grand Rounds will be maintained. The roster of staff Clinical case conference occurs regularly on Thursdays at 12 noon. In addition, longer
design and implement case conferences or Grand Rounds so that there is greater knowledge, skills, and support in working with class members with challenging behaviors. participation will be maintained by the Staff and Organizational Development Office. These data will be reported in the Quarterly Report. audiovisual conferences with faculty at Dartmouth College occur three times per year and will move to a similar Thursday noon slot for the next academic year. Attendance list for the clinical case conference is now kept, in addition to those individuals who wish to fill in the appropriate sheets to obtain continuing medical education (CME) credits. It is noted that attendance at the clinical case conference for academic year 2015 increased to 1142 from 694 in academic year 2014. This represents a 65 percent increase in attendance at the clinical case conferences. Attendance by nursing staff, acuity specialists, and mental health workers continues to lag behind other disciplines. For this reason, academic year 2016 has been identified as the year to ensure marked increase in nursing, acuity specialist, and mental health worker attendance. I have met with the current nursing leadership to set the expectation for nursing attendance at clinical case conference. The response CONSENT DECREE Recommendation Quality Improvement Measure Actions Taken During the Quarter has been positive. The previous commitment from director of nursing, R. Pushard, to provide relief from senior nursing so that unit nurses and mental health workers could attend the clinical case conference did not
used. The report will include (but is not limited to) information on: Documentation on certification and external reviews of behavioral management system Number of staff trained Number of staff retrained Results of inter-rater reliability tests for trainers Number of injuries Number of patient injuries Number of incident reports showing that Training data are reported in the hospital’s Quarterly Report. Injury data are reported in the hospital’s Quarterly Report. The Risk Manager continues to provide the Court Master a summary report of all seclusion and restraint events. CONSENT DECREE Recommendation Quality Improvement Measure Actions Taken During the Quarter staff varied from techniques Review of fact-findings or investigations where behavioral management system failed to achieve goals Findings from external reviews of the MOAB program The Risk Manager reviews 100% of all incident reports for seclusion and restraint daily to determine whether further actions are required. A summary report of 100% of all seclusion and restraint events
are sent to the Court Master weekly. In light of the current demographics of admissions to Riverview, the adequacy of staffing requires further independent review. It is highly recommended that staffing ratios be determined by acuity rather than by census on the units. The hospital will continue to monitor the staffing ratio as defined in the Consent Decree. In addition, the Integrated Quality team will work with Clinical Leadership to establish measurements to test the reliability and validity of data used with acuity based models to ensure that, in addition to meeting the Consent Decree’s minimum staffing ratios, staffing is sufficient to carry out Consent Decree requirements. Nursing works with staffing office daily to ensure that each unit, each shift has adequate numbers of staff based upon Consent Decree and taking into account a minimum of 8 additional acuity factors including: increased level of observation- medical issues – outside appointments – coercive events – admissions – discharges – increased dangerousness level - Nursing has offered flex shifts and is looking at unit based staffing. CONSENT DECREE Recommendation Quality Improvement Measure Actions Taken During the Quarter Riverview is cooperating with State Psychiatric Hospitals in Maine, Vermont and New Hampshire to test two acuity assessment tools: The “Modified Overt Aggression Scale” and the “Staff Observation Aggression Scale.” Meetings among staff at the hospitals are occurring to define measurement. A decision is being made to submit either single or multiple IRB applications for use of the instruments for research purposes. The use of "float" staff, especially those recently hired at Riverview, requires review in order to reduce the likelihood of risk due to unfamiliarity with and knowledge of the individuals with challenging behaviors or the need for specialized interventions. This 100% of new staff on acute units will have received and passed competency based skills training before being assigned. All new must complete skills training as outlined by the hospital prior to being released from orientation. Some of these skills include MOAB training, CPR & power point presentations with competency quizzes on the subjects of Incident Reports,
review is especially critical for any assignment to the Forensic Units. documentation, Patient Rights and seclusion/ restraint. There should be consideration of supplemental pay for staff assigned to the Lower Saco unit. The Human Resource office reviews its payroll records to ensure that staff who are eligible for the supplemental pay are receiving it according to Human Resource guidance. Effective 9/1/15, by contract, all MHW’s assigned to the Saco and Lower Kennebec units will receive a stipend of $1.00 per hour for hours worked on those units. Discussions should be held with Mental Health Workers and nursing to Action steps will be developed based on the results of the DHHS Human The day NOD and IV’s meet every weekday morning and have been meeting more CONSENT DECREE Recommendation Quality Improvement Measure Actions Taken During the Quarter determine what additional measures are required to reduce the pressures experienced by and the resulting effects on the class members hospitalized for treatment. Resources survey. The results of the survey and subsequent action steps will be reported to the Quality Improvement Committee and distributed to staff and included in the Quarterly Report. regularly to specifically develop a new staffing pattern to reduce staff stress. In addition, a more aggressive effort to quickly review Family Medical Leave requests is being created to assist in reducing these pressures. Qualification for Mental Health Workers should not be reduced. 100% of Mental Health workers meet and maintain the competencies required for positions. Applications for mental health workers are verified by Human Resources against the minimum qualifications established by the state DER (Employee Relations). If a candidate does not meet minimum qualifications they cannot proceed in the application process. Continuing effort is required to ensure that all staff understand the mandate for reporting any suspected abuse, neglect, or exploitation of class members. 100% of incidents of abuse, neglect or exploitation are reported to Adult Protective Services. This will be monitored by a monthly review of incident reports. On a bi-monthly basis, the hospital’s survey team (comprised of quality improvement staff from both Riverview and Dorothea Dix) will conduct an audit of the patient records for The Risk Manager continues to verify that all allegations of abuse, neglect or exploitation are reported to Adult Protective Services. All incidents are reviewed. A monthly report is sent to hospital’s Human Rights Committee for review. On a monthly review of Incident Reports, the hospital’s survey team (comprised of quality improvement staff from both
Community Dental, Region II Dr. Brendan Kirby Clinical Director All indicators met standards. Comprehensive Pharmacy Services Dr. Brendan Kirby Clinical Director All indicators met standards. Comtec Security Debora Proctor Executive Housekeeper All indicators met standards. Cummins Northeast Richard Levesque Director of Support Services All indicators met standards. Dartmouth Medical School Robert J. Harper Superintendent All indicators exceeded standards. Disability Rights Center Robert J. Harper Superintendent All indicators met standards. G & E Roofing Richard Levesque Director of Support Services No services were provided during this timeframe. Goodspeed & O’Donnell Dr. Brendan Kirby Clinical Director All indicators met standards. Liberty Healthcare – After Hours Coverage Dr. Brendan Kirby Clinical Director All indicators met or exceeded standards. Liberty Healthcare – Physician Staffing Dr. Brendan Kirby Clinical Director All indicators met standards. Maine General Community Care/Healthreach Dr. Brendan Kirby Clinical Director All indicators met standards. Maine General Medical Center – Laboratory Services Dr. Brendan Kirby Clinical Director All indicators met standards. JOINT COMMISSION Contractor Program Administrator Summary of Performance MD-IT Transcription Service Joseph Riddick Director of Integrated Quality & Informatics All indicators met standards. Mechanical Services Richard Levesque Director of Support Services All indicators met standards. Medical Staffing and Services of Maine Dr. Brendan Kirby Clinical Director All indicators met standards. Motivational Services Dr. Brendan Kirby Clinical director All indicators met or exceeded standards. Occupational Therapy Consultation and Rehabilitation Services Janet Barrett Director of Rehabilitation No services were provided during this timeframe. Otis Elevator Richard Levesque Director of Support Services All indicators met standards. Pine Tree Legal Assistance Dr. Brendan Kirby Clinical Director No services were provided during this timeframe. Project Staffing Cindy Michaud Business Services Manager All indicators exceeded standards.
All patients with tooth extractions will be assessed and have teaching post procedure on the following topics, as provided by the Dentist or Dental Assistant: Bleeding Swelling Pain Muscle soreness Mouth care Diet Signs/symptoms of infection The patient, post procedure tooth extraction, will verbalize understanding of the above by repeating instructions given by Dental Assistant/Hygienist. Post dental extraction patients will receive a follow-up call from the clinic within 24 hours of procedure to assess for post procedure complications Oct 100% 9/9 Nov 100% 3/3 Dec 100% 2/2 Total 100% 14/14 Jan 100% 4/4 Feb 100% 6/6 Mar 100% 4/4 Total 100% 14/14 April 100% 3/3 May N/A 0/0 June 100% 1/1 100% 4/4 July 100% 3/3 Aug N/A 0/0 Sept N/A 0/0 Total 100% 3/3 100% 35/35 JOINT COMMISSION Healthcare Acquired Infections Monitoring and Management NPSG.07.03.01 Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals. Infection Control Responsible George Davis, MD, Chairperson of Infection Control Committee Kathleen Mitton, RN, Infection Control Nurse I. Measure Name: Hospital Associated Infection (HAI) Rate Measure Description: Monitor and measure of Hospital Associated Infections. Measure Type: Quality Assurance Results Target Unit Baseline 2Q2015 3Q2015 4Q2015 1Q2016 YTD Within 1 STDV of the Mean Hospital Associated Infection Rate FY 2014 1 STDV within the mean 4 HAI/IC Rate 2.2 7 HAI/IC Rate 1.1 4 HAI/IC Rate 0.83 12 HAI/IC Rate 1.7 HAI – 1.46 Actual Outcome At 1 STDV 1 STDV within the mean 1 STDV within the mean
A Hospital Acquired Infection (HAI) is any infection present, incubating or exposed to more than 72 after admission (unless the patient is off hospital grounds during that time) or declared by a physician, a physician’s assistant or advanced practice nurse to be a HAI. A Community Acquired Infection (CAI) is any infection present, incubating or exposed to to admission; while on pass; during off-site medical, dental, or surgical care; by a visitor, any prophylaxis treatment of a condition or treatment of a condition for which the patient has a history of chronic infection no matter how long the patient has been hospitalized; or declared by the physician, physician’s assistant, or advanced practice nurse to be a community acquired infection. An Idiosyncratic Infection is any infection that occurs admission and is the result of the patient’s action toward himself or herself. JOINT COMMISSION Kennebec: Upper Saco: Acne Vulgaris – CAI Cellulitis Rt. Lower Leg - HAI Candida Intertrigo secondary to poor hygiene and diabetes - CAI Folliculitis/Question Fungal infection - CAI Lower Kennebec SCU: Traumatic Blister of the heal - CAI Chronic bacterial vaginosis – CAI Laceration left Thumb/? Human Bite - HAI Probable pre-septal cellulitis, either buccal or parotitis – HAI Prophylactic treatment - CAI Lesion Rt. Calf – HAI Chronic Testicular pain - CAI Lower Saco: Conjunctivitis - HAI Onychomycosis 2nd, 3rd, & 5th fingers Rt. Hand - CAI Eye (upper lid) infection - HAI Lyme Disease – CAI Paronychia secondary to ingrown nail - CAI Infected Toe – CAI Cellulitis Rt. Toe - HAI Sinus infection – HAI Lower Saco SCU: Herpes Simplex Genitalis – CAI Human Bite – HAI Cellulitis of Buttocks – HAI Acne – CAI Pneumonia – HAI Acute left Olecranis Bursitis with furuncle & cellulitis - HAI Question DVT/calf pain secondary to a fall – HAI Upper Kennebec: Rt. Great Toe infection secondary to ingrown toenail – CAI Dental Infection – CAI Data Analysis: Total Infections: 27 – 3.7 HAI: 12 – 1.7
JOINT COMMISSION Dispensing Process Measure Unit Baseline 2014 Goal 2Q 2015 3Q 2015 4Q 2015 1Q 2016 1. Controlled Substance Loss Data: Daily Pyxis-CII Safe Compare Report. All 0.875% 0% Target: Actual: 0% 0% 0% 0% 0% 0% 0% 0% 2. Controlled Substance Loss Data: Monthly CII Safe Vendor Receipt Report. Rx 0 0 Target: Actual: 0 0 0 0 0 0 0 0 3. Controlled Substance Loss Data: Monthly Controlled Drug discrepancies. All 22/mo 0 Target: Actual: 0 66 (22/ mo) 0 42 (14/ mo) 0 37 (12/ mo) 0 22 7/ mo 4. Medication Management Monitoring: Measures of drug reactions, adverse drug events and other management data. Rx 8/year 0 Target: Actual: 0 1 0 2 0 3 0 0 5. Medication Management Monitoring: Resource Documentation Reports of Clinical Interventions. Rx 99/ quarter 100% Target: Actual: 100% 79 100% 73 100% 56 100% 31 6. Psychiatric Emergency Process: Monthly audit of all psych emergencies measures against 9 criteria. All 100% 100% Target: Actual: 100% 95% 100% 93% 100% 94% 100% 78% 7. Operational Audit: Monthly audit of 3 operational indicators from CPS contract. Rx 100% 100% Target: Actual: 100% 100% 100% 100% 100% 100% 100% 100% 1Q2016: 6. One psych emergency (PE) was reported during the quarter. Two of the nine criteria were not met: MAR/s printed/brought to unit by RPh and PH checking new MARs vs. updated MARs completing by nursing & reconciliation performed. The PE ended over the weekend and it is unclear if the protocol was followed. Re-education will be done to correct the process.
STRATEGIC PERFORMANCE EXCELLENCE Capital Community Clinic Medication Management Clinic Responsible Robin Weeks, Medical Assistant Measure Name: Reconciliation of Outpatient Medication List Measure Description: Each visit will cover reconciliation of medical & psychotropic medications with patients. Measure Type: Performance Improvement Results Unit Baseline 2Q2015 3Q2015 4Q2015 1Q2016 YTD Target Reconciliation completed per visit. FY15 Q2 73% 100% 100% 100% 100% 100% Actual 73% 40/55 85% 46/54 100% 59/59 94% 59/63 88% 204/231 STRATEGIC PERFORMANCE EXCELLENCE Measure Name: Vital Signs Measure Description: Taking signs each visit will give us an idea of the effects of the prescribed medications and early detection of possible medical problems with the patient. Measure Type: Quality Improvement Results Unit Baseline 2Q2015 3Q2015 4Q2015 1Q2016 YTD Target Reconciliation completed per visit. FY15 Q1 73% 100% 100% 100% 100% 100% Actual 74% 40/54 61% 28/46 97% 57/59 92% 58/63 82% 183/222
Encourage front line supervisors to promote hand hygiene with their staff throughout the day. STRATEGIC PERFORMANCE EXCELLENCE Emergency Management Responsible Party: Robert Patnaude, Emergency Management Coordinator Measure Name: Communications Equipment/Two-way radios Measure Description: The Joint Commission states the following in EM.02.02.01: “As part of its Emergency Operations Plan, the hospital prepares for how it will communicate during emergencies. The hospital maintains reliable communications capabilities for the purpose of communicating response efforts to staff, patients, and external organizations.” In the event of an unforeseen emergency which could impact the safety and security of patients, staff, and visitors, communications equipment, more specifically, two-way radios are a major solution to getting accurate information to and from staff in a timely manner. The objective of the Emergency Management Communications PI is to ensure compliance with The Joint Commission standard with the overall objective of ensuring that the two-way radio system is fully functional and that staff are proficient in its use. Type of Measure: Performance Improvement Methodology: Each month, the Emergency Management Coordinator or designee will perform a combination of partial and hospital-wide radio drills. Such drills will utilize a specific form to track the drills (see attached). In conjunction with the drills, environmental rounds will be conducted for the purpose of inspecting communications equipment. Any deficiencies shall have the appropriate corrective measure immediately instituted until compliance is met. The numerator is the number of timely and appropriate responses by staff utilizing the two-way radios by assignments. The denominator will be the total number of two-way radios by assignments. Baseline Data: To assure that critical emergency information is disseminated in a timely and accurate manner, a minimum of 90% compliance has been established. This data will be reported monthly to the Emergency Management Committee, IPEC, and the Environment of Care (EOC) Committee. Areas that fail to meet the threshold will be immediately reported to the aforementioned committees. STRATEGIC PERFORMANCE EXCELLENCE
Results Unit Baseline 1Q2016 2Q2016 3Q2016 4Q2016 YTD Target Percent of timely and appropriate responses FY 2016 90% 90% 144/159 90% 144/159 90% 144/159 Actual 92% 147/159 92% 147/159 Data Analysis: With a significant amount of hands-on demonstrations, radio tests, and an increase in the use of radios, data showed that staff has become very familiar with operating the radio. Although the actual percentage of timely and appropriate responses has increased by 2%, the critical components such as having alert notification equipment in ready order needs improvement. We continue to investigate the most appropriate equipment that is not so dependent on staff oversight. Action Plan: Continued tests and remedial training to staff along with supporting handouts as needed. Increased surveillance of mass notification equipment such as alert pagers. Comments: 92% of assigned radio equipment is placed into service in a timely manner. This response adequately assures that the majority of occupants will receive timely and critical information. STRATEGIC PERFORMANCE EXCELLENCE Areas/Groups Monitored N = Numerator D = Denominator JUL 2015 AUG 2015 2015 OCT 2015 NOV 2015 DEC 2015 JAN 2016 FEB 2016 MAR 2016 APR 2016 MAY 2016 2016 Patient Care # of radios Job 1/ 1* 1/ 1 1/ 1* OPS/2 2/ 2* 2/2 1/ 2*1 Tx Mall, Clinic, Dietary, Med Rec/5 5/ 5* 5/5 3/ 5*2 US, UK, LS, LSSCU, LK, LKSCU/10 9/ 10 10/ 10 8/ 10*3
Overall 27% 17/63 27% 17/63 Comments: Percentages are calculated based on the number of people eligible to receive a survey vs. the number of people who completed the surveys. Inpatient Consumer Survey Results: # Indicators 2Q 2015 3Q 2015 4Q 2015 1Q 2016 Average 1 I am better able to deal with crisis. 79% 75% 69% 69% 73% 2 My symptoms are not bothering me as much. 71% 73% 69% 79% 73% 3 The medications I am taking help me control symptoms that used to bother me. 73% 71% 77% 75% 74% 4 I do better in social situations. 69% 73% 63% 71% 69% 5 I deal more effectively with daily problems. 69% 75% 71% 73% 72% 6 I was treated with dignity and respect. 65% 69% 73% 71% 69% 7 Staff here believed that I could grow, change and recover. 75% 74% 63% 69% 70% 8 I felt comfortable asking questions my treatment and medications. 73% 71% 54% 68% 66% 9 I was encouraged to use self-help/support groups. 77% 77% 56% 72% 71% 10 I was information about how to manage my medication side effects. 67% 60% 63% 68% 64% 11 My other medical conditions were treated. 56% 69% 65% 65% 64% 12 I felt this hospital stay was necessary. 67% 50% 67% 65% 62% STRATEGIC PERFORMANCE EXCELLENCE # Indicators 2Q 2015 3Q 2015 4Q 2015 1Q 2016 Average 13 I felt free to complain without fear of retaliation. 67% 54% 56% 69% 62% 14 I felt safe to refuse medication or treatment during my hospital stay. 60% 49% 54% 62% 56% 15 My complaints and grievances were addressed. 50% 63% 65% 63% 60% 16 I participated in planning my discharge. 60% 66% 38% 75% 60% 17 Both I and my doctor or therapists from the community were actively involved in my hospital treatment plan. 50% 52% 38% 63% 51% 18 I had an opportunity to talk with my doctor or therapist from the community to discharge. 57% 47% 54% 63% 55%