Admitted with primary diagnosis of mental retardation, traumatic brain injury, dementia, substance abuse or dependence. 0% 0% 0% 0% 0% CONSENT DECREE Peer Supports Quarterly performance data shows that in 3 out of 4 consecutive quarters: V8) 100% of all patients have documented contact with a peer specialist during hospitalization; V9) 80% of all treatment meetings involve a peer specialist. Indicators 1Q2015 2Q2015 3Q2015 4Q2015 Attendance at Comprehensive Treatment Team meetings. (v9) 45% 183/404 91% 381/482 96% 383/414 91% 383/414 Attendance at Service Integration meetings. (v8) 100% 80/80 Data not available 93% 26/28 61% 19/31 Contact during admission. (v8) 100% 80/80 100% 72/72 100% 43/43 100% 45/45 Community Integration/Bridging Inpatient & OPS. Inpatient trips OPS 100% 63 130 100% 71 163 100% 25 142 Peer Support will make an attempt to assist all patients in recognizing their personal medicine and filling out form. 100% 72/72 100% 43/43 100% 45/45 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. 30% 19/64 82% 46/56 62% 28/45 Grievances responded to on time by Peer Support, within 1 day of receipt. 100% 65/65 100% 98/98 100% 86/86 4Q2015:
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 1Q2015 2Q2015 3Q2015 4Q2015 Institutional Reports will be completed, reviewed internally, and delivered to the court within 10 business days of request. 25% 1/4 0% 0/5 0% 0/8 66% 2/3 The assigned CCM will review the new court order with the patient and document the meeting in a progress note or treatment team note. 100% 6/6 100% 3/3 100% 2/2 100% 3/3 Annual Reports (due in December) to the Commissioner for all inpatient NCR patients are submitted annually N/A 100% 25/25 N/A N/A 4Q2015: 1. Three Institutional Reports were done. Two of the reports were completed in the 10 business day timeframe. We revamped a process to track the reports in the quarter to get a better result for completion. CONSENT DECREE Staffing and Staff Training V23) Riverview performance data shows that 95% of direct care staff have received 90% of their annual training. Indicators 1Q2015 2Q2015 3Q2015 4Q2015 YTD 1. Riverview and Contract staff will attend CPR training 100% 62/62 100% 37/37 100% 26/26 98% 55/56 99% 180/ 181 2. Riverview and Contract staff will attend Annual training. 96% 109/113 83% 72/87 74% 34/46 89% 25/28 88% 240/ 274 3. Riverview and contract staff will attend MOAB training 92% 389/424 87% 393/451 99% 389/ 391 94% 421/446 93% 1592/ 1712 annually.
member potentially subject to such restrictive measures. Specifically, class members with a history of unacceptable behavior, such as aggression towards peers and/or staff, need to be reviewed again by the and restraint events to the Court Master. The Staff and Organizational Development Office will conduct its first annual review of the MOAB program and present results to Executive Leadership in January 2015. A weekly report of seclusion and restraint events is sent to the Court Master weekly. The Staff and Organizational Development Office has identified a consultant to conduct a review of the CONSENT DECREE Recommendation Quality Improvement Measure Actions Taken During the Quarter treatment team, and, if necessary, by an independent clinical consultant, to determine whether sufficiently individualized interventions are being designed and consistently implemented to replace unacceptable behavior with appropriate alternative behaviors. MOAB program and upon completion will present results to Executive Leadership. The reporting requirements by Paragraphs 188 and 189 of the Consent Decree should be completed as mandated. On an annual basis (starting in January 2015), the Staff and Organizational Development Office will present a report to Executive Leadership at the hospital on the Behavioral Management system being 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 staff injuries Riverview has identified a consultant with expertise in MOAB. The scope of work, deliverables and delivery date are being negotiated. The Staff and Organizational Development Office are working on the metrics to be reported. 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. Jonathan Alexis, consultant,
JOINT COMMISSION Contract Performance Indicators TJC LD.04.03.09 The same level of care should be delivered to patients regardless of whether services are provided directly by the hospital or through contractual agreement. Leaders provide oversight to make sure that care, treatment, and services provided directly are safe and effective. Likewise, leaders must also oversee contracted services to make sure that they are provided safely and effectively. FY 2015 Quarter 4 Results Contractor Program Administrator Summary of Performance Amistad Peer Support Services Stephanie George-Roy Director of Social Services All indicators exceeded standards. 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 or exceeded standards. Cummins Northeast Richard Levesque Director of Support Services No services were provided during this timeframe. Dartmouth Medical School Robert J. Harper Acting 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 No services were provided during this timeframe. 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 The 3 indicators did not meet standards: (1) Timeliness or services, (2) Regular test results will be available within 24 hours, and (3) Stat test results will be available within 2 hours.
Dental Clinic Post Extraction Prevention of Complications and Follow-up Indicators 1Q2015 2Q2015 3Q2015 4Q2015 Total 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 July 100% 5/5 Aug 100% 2/2 Sept 100% 3/3 Total 100% 10/10 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 Total 100% 4/4 100% 42/42 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 Party: George Davis, MD, Chairperson of Infection Control Committee Kathleen Mitton, RN, Infection Control Nurse Measure Name: Hospital Associated Infection (HAI) Rate Measure Description: Fourth Quarter Review of Hospital Associated Infections Measure Type: Quality Assurance Results Target Unit Baseline Q1 Q2 Q3 Q4 YTD 1 STDV within the Mean Hospital Associated Infection Rate FY 2014 1 STDV within the mean 9 HAI/IC Rate 1.6 4 HAI/IC Rate 2.2 7 HAI/IC Rate 1.1 4 HAI/IC Rate 0.83 HAI – 1.4 Actual 1 STDV within the At 1 STDV 1 STDV within the 1 STDV within the
The subcommittees of the MEC and the Integrated Performance Excellence Committee are the primary methods by which the medical staff monitor and analyze for trends all quality performance data as well as trends more specific to medical staff performance. The subcommittees, in turn, report their findings on a monthly basis to the Medical Executive Committee and to the Clinical Director for any needed action. The respective committees monitor the following indicators: Integrated Performance Excellence Committee (this is not a subcommittee of the Medical Staff but the Clinical Director serves as a member and is the primary liaison to the Medical Executive Committee). Psychiatric Emergencies Seclusion and Restraint Events Staff or Patient Injuries Priority I Incident Reports Other clinical/administrative department monitoring activity Pharmacy and Therapeutics Committee: Medication Errors Including Unapproved abbreviations Adverse Drug Reactions Pharmacy Interventions Antibiotic Monitoring Medication Use Evaluations Psychiatric Emergency process Medical Records Committee: Chart Completion Rate/Delinquencies Clinical Pertinence of Documentation of Closed Records Infection Control Committee: Infection Rates (hospital acquired and community acquired) Staff Vaccination Rates/Titers Utilization Management Committee: Admission Denials Timeliness of Discharges After Denials Peer Review and Quality Assurance Committee: Hospital-wide Core Measures and NASMHPD Data Patient Satisfaction Surveys Administrative concerns about quality Special quality improvement monitors for the current year (see also the Appendix and number 6 below). Reports from the Human Rights Committee regarding patient rights and safety issues Specific case reviews STRATEGIC PERFORMANCE EXCELLENCE 3. Performance or Process Improvement Teams: When requested by or initiated by other disciplines or by hospital administration, or when performance issues are identified by the medical staff itself during its monitoring activities, the Clinical Director will appoint a medical staff member to an ad hoc performance improvement team. This is generally a multidisciplinary team looking at ways to improve