Contact during admission. (v8) 100% 64/64 100% 49/49 100% 64/64 100% 51/51 Community Integration/Bridging Inpatient & OPS. Inpatient trips OPS 100% 58 127 100% 91 131 100% 26 204 100% 21 221 Peer Support will make a documented attempt to have patients fill out a survey before discharge or annually to evaluate the effectiveness of the peer support relationship during hospitalization. 22% 14/63 41% 20/49 46% 30/65 19% 9/48 Grievances responded to on time by Peer Support, within 1 day of receipt. 100% 161/161 100% 97/97 100% 77/77 89% 82/92 Peer Specialist will meet with resident’s within 48 hours of admission and complete progress note to document meeting. 100% 64/64 100% 49/49 100% 64/64 100% 51/51 Each resident has documented contact with a peer supporter during their (target is 100%). 100% 64/64 100% 49/49 100% 64/64 100% 51/51 Treatment Planning V10) 95% of patients have a preliminary treatment and transition plan developed within 3 working days of admission; Indicators 1Q2016 2Q2016 3Q2016 4Q2016 Service Integration Meeting and form completed by the end of the 3rd day. 100% 45/45 100% 45/45 100% 45/45 100% 45/45 Patient participation in Service Integration Meeting. 93% 42/45 95% 43/45 97% 44/45 95% 43/45 Social Worker participation in Service Integration Meeting. 100% 45/45 100% 45/45 100% 45/45 100% 45/45 Initial Comprehensive Psychosocial Assessments completed within 7 days of admission. 97% 44/45 95% 43/45 95% 43/45 93% 42/45 Initial Comprehensive Assessment contains summary narrative with conclusion and recommendations for discharge and Social 100% 45/45 100% 45/45 100% 45/45 100% 45/45
with the report of the first review due on or before July 1, 2016. The scope of the review and the selection of the independent consultant to require the approval of the Court Master. choice of consultant are under review at this time. I recommend that the mental health workers who are most familiar with the patients be invited by the charge nurse on the unit to attend at least the initial portion of the treatment team meetings for those patients in order to provide input and observations, and that acuity specialists be invited to attend whenever it is deemed appropriate by the charge nurse. Current and relevant portions of the treatment plans, such as interventions, shall be maintained on the unit and reviewed with the charge nurse by the mental health workers assigned to those patients. Changes are in process to determine how to best use the knowledge of the mental health workers in the treatment team meetings. This is reviewed and implemented on each unit in the hospital. Processes for ensuring that the most current treatment information is being made available to all staff on an ongoing basis. I recommend that unit activity logs be maintained on each unit and that the logs be reviewed at least on a monthly basis to determine whether any limitation in a patient’s access to treatment, services or outdoor areas has occurred. Unit activity logs are maintained on each unit. educators are training staff on the required documentation regarding any limitations to treatment, services or outdoor activities. Inpatient Psychiatric Services (ORYX Data Elements) The Joint Commission Quality Initiatives In 1987, The Commission announced its Agenda for Change, which outlined a series of major steps designed to modernize the accreditation process. A key component of the Agenda for Change was the eventual introduction of standardized core performance measures into the accreditation process. As the vision to integrate performance measurement into accreditation became more focused, the name ORYX® was chosen for the entire initiative. The ORYX initiative became operational in March of 1999, when performance measurement systems began transmitting data to The Joint Commission on behalf of accredited hospitals and long term care
with current law and HIPAA regulations needs to be strictly adhered to requiring training, education, and policy development at all levels. Actions: The above indicators will continue to be monitored. Regulatory and Compliance Standards in Documentation Ensuring Fiscal Responsibility in Documentation and Billing Practices Indicator and Rationale for Selection 1Q2016 2Q2016 3Q2016 4Q2016 Identification Data N/A N/A 100% 65/65 100% 51/51 Medical History, including chief complaint; HPI; past, social & family hx.; ROS, and physical exam w/in 24 hr. conclusion and plan N/A N/A 100% 65/65 100% 51/51 Summary of patient’s psychosocial needs as appropriate to the patients * N/A N/A 88% 57/65 61% 31/51 Psychiatric Evaluation in patient’s record w/in 24 hr of N/A N/A 99% 64/65 100% 51/51
Baseline Average Baseline Range Q32016 Average Q32016 Range April Average April Range May Average May Range June Average June Range Total Orders 12.1 0-31 11 1-37 13 1-37 14 2-37 13.8 2-37 Scheduled 4.9 0-17 7 0-21 6 1-20 7 1-20 6.7 0-21 PRNs 5.9 0-19 10 0-21 7 0-21 8 1-21 7.6 1-21 Medication Number Range Average Number of Patients (Baseline) 3Q2016 Average April May June 4Q2016 Average < 5 7 5 4 4 5 4 5 – 9 30 18 24 20 18 21 10 – 14 38 32 32 32 28 31 15 – 19 15 15 11 16 20 16 20 – 24 4 9 8 9 8 8 25 – 29 2 3 5 4 4 4 > 30 2 1 3 3 3 3 Number of Patients Falling into Range of Medication Orders Nursing Responsible Renee Pfingst, RN, Acting Director of Nursing I. Measure Name: Mandate Occurrences Definition: When no volunteers are found to cover a required staffing need, an employee is mandated to cover the staffing need according to policy. This creates difficulty for the employee who is required to unexpectedly stay at work up to 16 hours. It also creates a safety risk. Objective: Through collaboration among direct care staff and management, solutions will be identified to improve the staffing process in order to reduce and eventually eliminate mandate
10 10. Dangerous Risk Tool done upon admission 50/50 100% 11 11. of 11 or above incorporated into Safety Problem 12/50 13 N/A 50% 12. Evidence of informed of their rights documentation 47/50 1 Refused 96% 13. Medication Reconciliation @ time of admission includes all medications (medical & psychiatric) 49/50 98% Outpatient Services (OPS) Responsible Party: Lisa Manwaring, Director I. Measure Name: Admission Assessments Measure Description: Within 5 business days of admission initial assessments from Psychiatry, Psychosocial, and Nursing will be complete and in the chart. All three will need to be present to count. Measure Type: Performance Improvement Results Unit Baseline 1Q2016 2Q2016 3Q2016 4Q2016 YTD Target Percent of assessments completed on time FY 2015 0% 0/4 75% 75% 75% 75% 75% Actual 0% 0/3 0% 0/5 0% 0/4 25% 1/4 .06% 1/16 Data Analysis: We had three charts with two assessments completed this quarter. Action Plan: To review data results with the OPS staff to ensure compliance. Comments: To provide education and admission packets with assessment reminders to help facilitate compliance. Peer Support