*If a field is blank it means that there were no admissions for that legal status during that timeframe Number of Discharges: Average Length of Stay (Days): *If a is blank it means that there were no discharges for that legal status during that timeframe 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 1Q2018 2Q2018 3Q2018 4Q2018 YTD Target NCR referrals admitted within 24 hours 4Q2017 100% 5/5 100% 100% 100% 100% 100% Actual 100% 4/4 100% 4/4
Results Unit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD Target Noted Daily; Reviewed Quarterly FY2017 95% 90-100% 90-100% 100% 100% 100% Actual 98% 98% Data Analysis: All patients that are seen prior to restorations and prophy appointments; denture patients do not always have their blood pressure taken, especially on denture deliveries. 1Q2018: July 2017 Yes: 20 No: 0 August 2017 Yes: 19 No: 1 September 2017 Yes: 20 No: 0 Action Plan: Need to discuss with Hygienists who work on Friday, that BP needs to be taken on all dental patients. Continue to take blood pressure and pulse at the start of all dental appointments. To withstand dental care, blood pressure should be less than 160/90. Comments: Data is collected from quarterly reviews by Community Dental. Twenty random charts were evaluated. VI. Measure Name: Treatment Plan Measure Description: Updating treatment plan yearly Type of Measure: Performance Improvement Results Unit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD Target Checked Monthly; Reviewed Quarterly New Measure 90-100% 90-100% 100% 100% 100% Actual 93% 93% Data Analysis: This is a new measure for FY2018. Patients not showing up for their recall appointments may make this difficult. 1Q2018: July 2017 Yes: 19 No: 1 August 2017 Yes: 19 No: 1 September 2017 Yes: 20 No: 0
Action Plan: Evaluate treatment plans for completeness and update yearly. Comments: Data is collected from quarterly reviews by Community Dental. Twenty random charts were evaluated. VII. Measure Name: Infection Control Measure Description: Instruments are checked with each load Type of Measure: Quality Assurance Results Unit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD Target Noted Daily; Reviewed Quarterly New Measure 100% 100% 100% 100% 100% Actual 100% 100% Data Analysis: To insure safety to our patients and staff, each load is checked prior to release of instruments for proper sterilization. 1Q2018: Pass 139 Fail 0 Action Plan: After each sterilization cycle, the dental staff checks steam indicator on each pouch and Steam SAFE and records PASS or FAIL onto the log. These results are reviewed daily and discussed at monthly staff meetings. Comments: Data is collected and reviewed at each staff meeting. VIII. Measure Name: Darkroom Test Measure Description: Efficiency of the darkroom and safe light (red light) Type of Measure: Quality Assurance Results Unit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD 100% 100% 100% 100% 100%
Discharge summaries will be completed within 15 days of discharge. Out of 63 discharge summaries, 50 were completed within 15 days of discharge. 79% 100% All forms/revisions to be placed in the medical record will be approved by the Medical Records Committee. Three revised forms, two new forms, and one deleted in 1Q2018 (see minutes). 100% 100% Medical transcription will be timely and accurate. 642 dictated reports were completed within 24 hours. 100% 90% Data Analysis: The indicators are based on the review of sample discharged records. There was a 95% compliance with 30-day record completion. Weekly “charts needing attention” lists are distributed to medical staff, including the Medical Director, along with the Superintendent, Risk Manager and the Quality Improvement Manager. There was 100% compliance with timely & accurate medical transcription services. Actions: Continue to monitor. II. Measure Name: Confidentiality Indicators 1Q2018 Findings 1Q2018 Compliance Target All patient information released from the Health Information Department will meet all Joint Commission, State, Federal & HIPAA standards. 3,242 Requests for information (192 requests for patient information and 3,050 police checks) were released. 100% 100% All new employees/contract staff will attend confidentiality/HIPAA training. All new employees/contract attended confidentiality/HIPAA training. 100% 100% Patient confidentiality/privacy issues tracked through incident reports. 0 privacy incident reports. Summary: The indicators are based on the review of all requests for information, orientation for all new employees/contract staff and confidentiality/privacy-related incident reports.
No problems were in 1Q2018 related to release of information from the Health Information Department and training of new employees/contract staff, however compliance with current law and HIPAA regulations need to be strictly adhered to requiring training, education and policy development at all levels. Actions: The indicators will continue to be monitored. III. Measure Name: Regulatory and Compliance Standards in Documentation Ensuring Fiscal Responsibility in Documentation and Billing Practices Indicator and Rationale for Selection 1Q2018 2Q2018 3Q2018 4Q2018 YTD Identification Data 100% 63/63 100% 63/63 Medical History, including chief complaint; HPI; past, social & family hx.; ROS, and physical exam w/in 24 hr. conclusion and plan 95% 60/63 3>24 hrs 95% 60/63 3>24 hrs Summary of patient’s psychosocial needs as appropriate to the patients * 75% 47/63 16>7 days 75% 47/63 16>7 days Psychiatric Evaluation in patient’s record w/in 24 hrs. of admission 89% 56/63 7>60 hrs 89% 56/63 7>60 hrs Physician (TO/VO w/in 72 hr.) 95% 111/117 95% 111/117 Evidence of appropriate informed consent 91% 61/63 91% 61/63 Clinical observations including the results of therapy. 100% 63/63 100% 63/63 Nursing discharge Progress Note with time of discharge departure 78% 49/63 78% 49/63 Consultation reports, when applicable 95% 131/144 95% 131/144 Results of autopsy, when performed 97% 61/63 97% 61/63 Advance Directive Status on admission and SW follow up 100% 63/63 100% 63/63 Notice of Privacy 95% 60/63 95% 60/63 Chart Completion w/in 30 days of discharge date/discharge summary completed within 30 days 79% 50/63 79% 50/63 Discharge Packet sent to follow up provider within five days of discharge. 100% 63/63 100% 63/63 * The parameters for this measure will be changed to meet applicable goals as defined by the Director of Social Work. The current measure is more stringent than regulatory standards dictate.
Definition: When no volunteers are 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. Type of Measure: Performance Improvement 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 occurrences. This process will foster safety in culture and actions by improving communication, improving staffing capacity, mitigating risk factors, supporting the engagement and empowerment of staff. It will also enhance fiscal accountability by promoting accountability and employing efficiency in operations. Methods of monitoring: Monitoring be performed by: Staffing Office Database Tracking System Human Resources Department Payroll System Methods of reporting: Reporting occur by one or all of the following methods: Staffing Improvement Task Force Nursing Leadership Riverview Nursing Staff Communication Unit: Mandate shift occurrences Baseline: September 2013: Nurse Mandates 14 shifts, Mental Health Worker Mandates 49 shifts Mandate Occurrences: When no volunteers are found to cover a required staffing need, an employee is mandated to cover the staffing need according to policy. Baseline Sept 2013 1Q2018 2Q2018 3Q2018 4Q2018 Goal July 2017 Aug 2017 Sept 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 June 2018 Nursing Mandates 14 0 8 0 0 Mental Health Worker (MHW) Mandates 49 0 1 0 0
A assessment is completed each shift. 44/60 73% Weekly Summary note completed. 58/60 97% Observational note completed on patient who is on a higher level of observation i.e. ¼ hour checks or 1:1. 35/60 24 N/A 98% Annual nursing assessment completed. 26/60 30 N/A 93% Patient’s Rights reviewed and signed. 55/60 1 Refused 1 LOC 95% Informed Consent signed, dated and timed. 51/60 1 Refused 5 LOC 95% Number of Telephone Orders for the month. 133/133 100% Number of Telephone Orders signed by the prescriber within 24 hours. 129/133 97% Percentage of patient mall attendance for the - - Is the patient prescribed 10 core groups? 47/60 3 N/A 1 LOC 85% Is the patient maintaining 75% of core group attendance? 17/60 13 N/A 1 LOC 52% Were patient’s levels changed if less than 75% attendance in core groups? 19/60 33 N/A 1 LOC 88% MHW/AS attendance at all treatment team meetings? 43/60 2 N/A 1 LOC 77% Attendance of on unit groups for patients too sick to go to the mall. 16/60 25 N/A 5 Refused 1 LOC 78% Treatment plan reviewed/modified every 2 weeks. 57/60 3 N/A 100% Suicide risk assessment reviewed/modified every 2 weeks during the 46/60 100%
the primary tool for collecting data on how patients feel about the services they are provided at the hospital. LS 50% 50% 5/10 50% 5/10 UK 50% 84% 21/25 84% 21/25 US 50% 100% 3/3 100% 3/3 Overall 50% 66% 33/50 66% 33/50 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 2018 2Q 2018 3Q 2018 4Q 2018 YTD Average 1 I am better able to deal with crisis. 61% 61% 2 My symptoms are not bothering me as much. 61% 61% 3 The medications I am taking help me control symptoms that used to bother me. 62% 62% 4 I do better in social situations. 62% 62% 5 I deal more effectively with problems. 63% 63% 6 I was treated with dignity and respect. 64% 64% 7 Staff here believed that I could grow, change and recover. 62% 62% 8 I felt comfortable asking questions about my treatment and medications. 65% 65% 9 I was encouraged to use self-help/support groups. 67% 67% 10 I was given information about how to manage my medication side effects. 62% 62% 11 My other medical conditions were treated. 63% 63% 12 I felt this hospital stay was necessary. 359% 359% 13 I felt free to complain without fear of retaliation. 62% 62% 14 I felt safe to refuse medication or treatment during my hospital stay. 60% 60% 15 My complaints and grievances were addressed. 60% 60% 16 I participated in planning my discharge. 62% 62%
CTS.02.01.03 EP1 Initial Assessments 100% 100% CTS.02.01.03 EP4 Family input gathered for patient assessment 100% 100% CTS.03.01.05 EP1, EP2 Family invited to participate in training 100% 100% HRM.01.01.01 EP1 All job descriptions have signatures 100% 100% EC.02.02.01 EP5 Eye Wash Stations in 100% 100% EC.02.03.03 EP3 Fire Drills adequately spaced 100% 100% EC.02.03.05 EP3, EP 4, EP9 All equipment is documented 100% 100% EC.02.04.01 EP4 Equipment Preventative Maintenance Schedule 100% 100% EC.02.05.01 EP8 Breaker Panel Labeled 100% 100% EC.02.06.01 EP1 Piano Hinges on Seclusion door 100% 100% EC.02.06.05 EP2 Evaluate Infection Control during building construction 100% 100% HRM.01.01.01 EP1 All job descriptions have signatures 100% 100% HRM.01.01.03 EP2 All clinicians licensed in Maine 100% 100% HRM.01.02.01 EP1, EP2 Primary Source verification 100% 100% HRM.01.03.01 EP2 Staff orientation to specific services 100% 100%