Attendance at Comprehensive Treatment Team meetings. (v9) *96% 383/414 *89% 331/401 *86% 446/515 *91% 442/484 Attendance at Service Integration meetings. (v8) 66% 12/31 *97% 61/63 96% 47/49 *86% 56/65 Contact during admission. (v8) 100% 45/45 100% 64/64 100% 49/49 100% 64/64 Community Integration/Bridging Inpatient & OPS. Inpatient trips OPS 100% 25 142 100% 58 127 100% 91 131 100% 26 204 Peer Support will make an attempt to assist all patients in recognizing their personal medicine and filling out form. 100% 45/45 0% 0/64 82% 40/49 78% 50/64 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. 62% 28/45 22% 14/63 41% 20/49 46% 30/65 Grievances responded to on time by Peer Support, within 1 day of receipt. 100% 86/86 100% 161/161 100% 97/97 100% 77/77 Peer Specialist will meet with resident’s within 48 hours of admission and complete progress note to document meeting. New Indicator Added FY 2016 100% 64/64 100% 49/49 100% 64/64 Each resident has documented contact with a peer supporter during (target is 100%). New Indicator Added FY 2016 100% 64/64 100% 49/49 100% 64/64 Treatment Planning V10) 95% of patients have a preliminary treatment and transition plan developed within 3 working days of admission; Indicators 4Q2015 1Q2016 2Q2016 3Q2016 1. 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
2. Patient participation in Service Integration Meeting. 95% 43/45 93% 42/45 95% 43/45 97% 44/45 3. Social Worker participation in Service Integration Meeting. 100% 45/45 100% 45/45 100% 45/45 100% 45/45 4. Initial Comprehensive Psychosocial Assessments completed within 7 days of admission. 95% 43/45 97% 44/45 95% 43/45 95% 43/45 5. Initial Comprehensive Assessment contains summary narrative with conclusion and recommendations for discharge and Social Worker role. 100% 45/45 100% 45/45 100% 45/45 100% 45/45 6. Annual Psychosocial Assessment completed and current in chart. 100% 10/10 100% 10/10 100% 10/10 100% 10/10 3Q2016: 2. One patient declined to meet for the Service Integration meeting and declined on follow up. 4. Two Comprehensive Psychosocial Assessments were not completed within the 7 day timeframe. V11) 95% of patients also have individualized treatment in their records within 7 days thereafter; Indicators 4Q2015 1Q2016 2Q2016 3Q2016 Progress notes in GAP/Incidental/Contact format will indicate at minimum weekly 1:1 meeting with all patients on assigned CCM caseload. 100% 45/45 91% 41/45 96% 43/45 89% 40/45 Treatment plans will have measurable goals and interventions listing patient strengths and areas of need related to transition to the community or transition back to a correctional facility. 100% 45/45 100% 45/45 100% 45/45 100% 45/45 3Q2016: During chart audits, four charts had a late progress note for the prior week. A meeting was held with the patient, but the note was a late entry. Issue was discussed with individual team members and support was given in supervision.
The record reflects that the patient was released as necessary for eating, drinking, bathing, toileting or special medical orders. 90% N/A The record reflects that the patient’s extremities were released sequentially, with one released at least every fifteen minutes. 90% N/A Copies of events were forwarded to Clinical Director and Patient Advocate. 90% N/A For persons with mental retardation, the applicable regulations were met. 85% N/A The record reflects that the order was not entered as a PRN order. 90% N/A Where there was a PRN order, there is evidence that physician was counseled. 95% N/A A restraint event that exceeds 24 hours will be reviewed against the following requirement: If total consecutive hours in restraint, with renewals, exceeded 24 hours, the record reflects that the patient was medically assessed and treated for any injuries; that the order extending restraint beyond 24 hours was entered by Clinical Director (or if the Clinical Director is out of the hospital, by the individual acting in the Clinical Director’s stead) following examination of the patient; and that the patient’s guardian or representative has been notified. 90% N/A Patient Elopements V31) Quarterly performance data that, in 5 out of 6 quarters, the number of patient elopements does not exceed one standard deviation from the national mean as reported by NASMHPD. This depicts the number of elopements that occurred for every 1000 inpatient days. For example, a rate of 0.25 means that 1 elopement occurred for each 4000 inpatient days. An elopement is defined as any time a patient is “absent from a location defined by the patient’s privilege status regardless of the patient’s leave or legal status.” The following graphs depict the number of elopements stratified by forensic or civil classifications that occurred for every 1000 inpatient days. For example, a rate of 0.25 means that 1 elopement occurred for each 4000 inpatient days. The hospital-wide results from
Comprehensive Pharmacy Services Dr. William Nelson Clinical Director All indicators met standards. Comtec Security Richard Levesque Director of Support Services All indicators met standards. Cummins Northeast Richard Levesque Director of Support Services All indicators met standards. Dartmouth Medical School Jay Harper Superintendent All indicators met standards. Disability Rights Center Jay Harper Superintendent All indicators met standards. G & E Roofing Richard Levesque Director of Support Services Indicator exceeded standards. Goodspeed & O’Donnell Dr. William Nelson Clinical Director No services were provided during this timeframe. Liberty Healthcare – After Hours Coverage Dr. William Nelson Clinical Director All indicators exceeded standards. Liberty Healthcare – Physician Staffing Dr. William Nelson Clinical Director All indicators met standards. Main Security Surveillance Richard Levesque Director of Support Services All indicators met standards. Maine General Community Care/HealthReach Dr. William Nelson Clinical Director All indicators met standards. Maine General Medical Center – Laboratory Services Dr. William Nelson Clinical Director All indicators met standards. Contractor Program Administrator Summary of Performance MD-IT Transcription Service Samantha Brockway Medical Records Administrator All indicators met standards. Mechanical Services Richard Levesque Director of Support Services No services were provided during this timeframe. Medical Staffing and Services of Maine Dr. William Nelson Clinical Director All indicators met standards. Motivational Services Dr. William Nelson Clinical director All indicators met or exceeded standards. Occupational Therapy Consultation and Rehabilitation Services Janet Barrett Director of Rehabilitation All indicators met or exceeded standards.
A time out will be taken before the procedure to verify location and numbered tooth. The time out section is in the progress notes of the patient chart. This page will be signed by the Dentist as well as the Dental Assistant. June 100% 1/1 Total 100% 4/4 Sept N/A 0/0 Total 100% 3/3 1/1 Total 100% 4/4 N/A 0/0 Total 8/8 Dental Clinic Post Extraction Prevention of Complications and Follow-up Indicators 4Q2015 1Q2016 2Q2016 3Q2016 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 phone call from the clinic within 24 hours of procedure to assess for post procedure complications April 100% 3/3 May N/A 0/0 June 100% 1/1 Total 100% 4/4 July 100% 3/3 Aug N/A 0/0 Sept N/A 0/0 Total 100% 3/3 Oct 100% 2/2 Nov 100% 1/1 Dec 100% 1/1 Total 100% 4/4 Jan 100% 5/5 Feb 100% 3/3 Mar N/A 0/0 Total 8/8 100% 19/19 Healthcare Acquired Infections Monitoring and Management NPSG.07.03.01 Implement practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals.
Responsible Party: Jamie Meader, RN, Admissions Nurse Number of Admissions: Average Number of Wait Days: *If a field is blank it means that there were no admissions for that legal status and timeframe Number of Discharges: Average Length of Stay (Days): I. Measure Name: NCR Admissions Measure Description: Admittance of all NCR patients within 24 hours of referral Type of Measure: Quality Assurance Results Unit Baseline 1Q2016 2Q2016 3Q2016 4Q2016 YTD Target NCR referrals admitted within 24 N/A 100% 100% 100% 100% 100% Actual 86% 6/7 100% 2/2 100% 6/6 93% 14/15
Comments: Trying to educate our patients on brushing and its importance for proper oral care and retention of teeth. Data collected from daily collected plaque scores as of the Q3 only on hygiene recall appointments. III. Measure Name: Next Visit Measure Description: Writing Next in progress note. Type of Measure: Performance Improvement Results Unit Baseline 1Q2016 2Q2016 3Q2016 4Q2016 YTD Target # of progress notes with next visit documented 66% FY 2015 70% 75% 80% 85% 90% Actual 60% 95% 95% 83% Data Analysis: FY2015 YTD was 66%; therefore, it has become a performance improvement measure. We would like this measure to be at 90 – 100%. Action Plan: Write at the end of every progress note what the next visit is going to be even if it is a 3 MRC or denture adjustment as needed. Comments: Data collected from quarterly reviews by Community Dental; evaluate twenty random charts. IV. Measure Name: RMH and MEDS Measure Description: Review medical history and medications at the start of each appointment. Type of Measure: Quality Assurance Results Unit Baseline 1Q2016 2Q2016 3Q2016 4Q2016 YTD Target Daily noted New implemented measure 70% 80% 90% 100% Actual 90% 95% 100% 95%
Quarterly Targets: Quarterly targets vary based on unit baseline with the end target being 50%. Survey Return Rate Unit Baseline Target 1Q2016 2Q2016 3Q2016 4Q2016 YTD The inpatient consumer survey is the primary tool for collecting data on how patients feel about the services they are provided at the hospital. LK 15% 50% 44% 7/16 23% 3/13 64% 7/11 43% 17/40 LS 5% 50% 0% 0/21 54% 7/13 13% 2/16 18% 9/50 UK 45% 50% 18% 3/17 25% 4/16 19% 5/26 20% 12/59 US 30% 50% 88% 7/8 100% 7/7 0% 0/5 70% 14/20 Overall 31% 52/169 Comments: Percentages are calculated on the number of people eligible to receive a survey vs. the number of people who completed the surveys. Inpatient Consumer Survey Results: # Indicators 1Q 2016 2Q 2016 3Q 2016 4Q 2016 YTD Average 1 I am better able to deal with crisis. 69% 82% 53% 68% 2 My symptoms are not bothering me as much. 79% 77% 64% 73% 3 The medications I am taking help me control symptoms that used to bother me. 75% 70% 42% 62% 4 I do better in social situations. 71% 64% 56% 64% 5 I deal more effectively with daily problems. 73% 83% 64% 73% 6 I was treated with dignity and respect. 71% 65% 56% 64% 7 Staff here believed that I could grow, change and recover. 69% 62% 56% 62% 8 I felt comfortable asking questions about my treatment and medications. 68% 68% 72% 69% 9 I was encouraged to use self-help/support groups. 72% 75% 58% 68%