The record reflects that, for persons with mental retardation, the regulations governing seclusion of patients with mental retardation were met. 85% 100% The medical order for seclusion was not entered as a PRN order. 90% 100% Where there was a PRN order, there is evidence that physician was counseled. 95% N/A Confinement Events Management 4Q2017 Mechanical Restraint Events (0) Events
Capital Community Dental Clinic assures accurate patient identification by asking the patient to state his/her name and date of birth. 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 Dental as well as the Dental Assistant. N/A N/A N/A 100% 1/1 Sept 100% 7/7 Dec 100% 1/1 Mar 100% 3/3 Jun 100% 6/6 Total 100% 7/7 Total 100% 5/5 Total 100% 3/3 Total 100% 10/10 Dental Clinic Post Extraction Prevention of Complications and Follow-up Indicators 1Q2017 2Q2017 3Q2017 4Q2017 YTD 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 N/A Oct 100% 4/4 Jan N/A Apr 100% 3/3 100% 25/25 Aug N/A Nov N/A Feb N/A May 100% 1/1 Sept 100% 7/7 Dec 100% 1/1 Mar 100% 3/3 Jun 100% 6/6 Total 100% 7/7 100% 5/5 Total 100% 3/3 Total 100% 10/10 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.
Type of Fall by Patient and Month Fall Type Patient April May June 4Q2017 Un-witnessed 1 1 MR726 1 1 MR1872 1 1 MR4974* 4 4 Totals 2 5 0 7 Fall Type Patient April May June 4Q2017 Witnessed MR83 1 1 MR86 2 2 MR107 4 4 MR684* 2 2 MR2951 1 1 MR4702 1 1 MR4974* 2 2 MR7809 2 2 MR7983 1 1 MR8044 2 2 Totals 8 8 2 18 *Indicates that the patient had both un-witnessed and witnessed in the 4Q2017 Admissions Responsible Party: Samantha Newman, RN, Admissions Nurse Number of Admissions:
Measure Description: Complete a full periodontal charting. Type of Measure: Performance Improvement Results Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD Target % of recall appointments where full mouth periodontal charting was completed FY2016 51% 50% 55% 60% 65% 65% Actual 33% 69% 68% 76% 62% Data Analysis: To better report this measure, we will only measure periodontal charting on existing patients during prophylactic recall appointments. Hygienist will note in the chart those patients that she is unable to chart because of limited chair time (i.e. patients with low function intellectual disability.) April 2017 = 51/65 = 78% May 2017 = 66/96 = 68% June 2017 = 44/58 = 76% Action Plan: Charting to be completed by the hygienist during prophy appointments only and not during emergency or new patient appointments, in to get a more accurate percentage. Comments: Definite improvement throughout the year. We will continue to monitor next year. II. Measure Name: Improving Oral Hygiene Measure Description: Monitoring and working to improve patients’ oral hygiene Type of Measure: Performance Improvement Results Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD Target Recall Hygiene Prophy New Measure 50% 55% 60% 65% 65% Actual 50% 44% 56% 42% 48% Data Analysis: Percentage of patients with Excellent or Good Hygiene. The goal is to stay above 65% and continuously improve to 75%.
Human Resources Person Responsible: Rice, Human Resources Manager I. Measure Name: License Reviews Measure Description: Ensuring that licenses/registry entries are verified via the appropriate source to hire for all licensed (or potentially licensed) new hires. Type of Measure: Quality Assurance Results Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD Target Percentage Licenses Reviewed FY2014 98% 100% 100% 100% 100% 100% Actual 100% 24/24 100% 15/15 100% 22/22 100% 20/20 100% 81/81 Data Analysis: During 4Q2017, were 25 new hires. Of those, 20 were licensed, or potentially licensed. License verification was completed on all 20 employees with potential licenses. Action Plan: No action is needed at this time. Infection Control Person Responsible: Donna Bradeen, RN, Infection Control Nurse I. Measure Name: Employee Hand Hygiene Rate Measure Description: will observe the hand hygiene practice of nurses as they pass medications. (10 observations per month) Staff will do 10 hand hygiene observations per month (before & after patient contact) in the milieu on the 7AM-7PM shift. Staff will do 10 hand hygiene observations per month (before & after patient contact) in the milieu on the 7PM-7AM shift Measure Type: Performance Improvement
Baseline TSH ECG (for patients >40 of age) Pregnancy test CBC LFTs Albumin Sodium Ammonia Pregnancy Test CBC LFTs Albumin Electrolytes Pregnancy Test Serum Levels At steady state 3-6 months As clinically indicated At steady state As clinically indicated Two levels to establish dose, four weeks apart As clinically indicated Longitudinal Monitoring Every three months Once At 3months: BUN SCr TSH Every three months for the 1st year of therapy: Weight CBC LFTs Albumin Sodium Monthly for three months: CBC LFTs Albumin Electrolytes BUN SCr Every six months --- --- Every 12 months Weight Weight CBC LFTs Albumin Sodium BP* Bone density* FBG Fasting lipids* CBC LFTs Albumin Electrolytes BUN SCr *If there are clinical risk factors BP – blood pressure; BUN – blood urea nitrogen; CBC – complete blood count; ECG – echocardiogram; FBG – fasting blood glucose; FLP – fasting lipid profile; LFTs – liver function tests; SCr – serum creatinine; TSH – thyroid stimulating hormone; VPA – valproic acid and derivatives Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 Target Laboratory Parameters 79% (FY2016) 90% 90% 90% 90% Actual 60% 42% 47% 72%
A assessment is completed each shift. 48/60 80% Weekly Summary note completed. 59/60 1 n/a 100% Observational note completed on patient who is on a higher level of observation i.e. ¼ hour checks or 1:1. 36/60 24 n/a 100% Diabetes teaching checklist active/completed (if patient is diabetic). 10/60 49 n/a 98% Multidisciplinary Teaching checklist active/completed. 58/60 97% Dental education teaching checklist active/completed. 56/60 93% Nursing Assessment of Suicide Risk completed with Treatment Plan Review. 60/60 100% Annual Assessment completed. 21/60 38 n/a 1 ref. 100% Patient’s rights reviewed and signed. 38/60 8 ref. 4 loc. 83% Informed Consent signed, and timed. 43/60 8 ref. 8 loc. 98% Number of Telephone Orders for the 95/95 100% Number of Telephone Orders signed by the prescriber within 24 hours. 87/95 92% Peer Support Responsible Julia Duncan, Peer Support Coordinator I. Measure Name: Inpatient Consumer Survey Return Rate
Measure Description: There is a low number of satisfaction surveys completed and returned once offered to patients due to a number of factors. Objective: To increase the number of surveys offered to patients, as well as increase the return rate. Those responsible for Monitoring: Peer Support Director and Peer Support Team Leader will be responsible for developing tracking tools to monitor survey due dates and surveys that are offered, refused, and completed. Peer Support Staff will be responsible for offering surveys to patients and tracking them until the responsibility can be assigned to one person. Methods of Monitoring: Biweekly supervision check-ins Monthly tracking sheets/reports submitted for review Methods of Reporting: Patient Satisfaction Survey Tracking Sheet Completed surveys entered into spreadsheet/database Unit: All patient care/residential units Baseline: Determined from previous year’s data. Quarterly Targets: Quarterly targets vary on unit baseline with the end target being 50%. Survey Return Rate Unit Target 1Q2017 2Q2017 3Q2017 4Q2017 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 50% 8% 1/13 50% 4/8 59% 10/17 92% 11/12 52% 26/50 LS 50% 0% 0/12 90% 9/10 14% 2/14 44% 4/9 30% 15/45 UK 50% 0% 0/18 25% 6/24 48% 13/27 52% 12/23 33% 31/92 US 50% 16% 1/6 44% 7/16 60% 3/5 50% 2/4 41% 13/31 Overall 4% 2/49 45% 26/58 41% 28/68 60% 29/48 38% 85/223 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: 1Q 2017 2Q 2017 3Q 2017 4Q 2017 YTD Average
Comments: The 4Q2017 reported a lower number of Rx’s for discharges. The cost of a 4Q2017 prescription was $13.40, a $6.27 decrease from 3Q2017, and a $1.78 decrease from the 2016 baseline figure. The development of a new formulary and transitions of care program to minimize the dispensing of medications to patients returning to correctional facilities has proven effective in decreasing this metric. V: Measure Name: Dispensing Process Measure Unit Baseline 2016 Goal 1Q 2017 2Q 2017 3Q 2017 4Q 2017 1. Controlled Substance Loss Data: Daily Pyxis-CII Safe Compare Report. All 0.19% 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: 0 Actual: 0 0 0 0 0 0 0 0 0 3. Controlled Substance Loss Data: Monthly Pyxis Controlled Drug Discrepancies. All 0/mo Target: 0 Actual: 0 0 39 (13/ mo) 0 44 (15/ mo) 0 35 (12/ mo) 0 14 (4.6/ mo) 4. Medication Management Monitoring: Measures of drug reactions, adverse drug events, and management data. Rx 10/year Target: 0 Actual: 0 0 10 0 2 0 8 0 0 5. Medication Management Monitoring: Resource Documentation Reports of Clinical Interventions. Rx 136/ quarter 100% Target: Actual: 100% 167 100% 129 100% 351 100% 330 6. Psychiatric Emergency Process: Monthly audit of all psych emergency measures against eight criteria. All 100% 100% Target: Actual: 100% 100% 100% 96% 100% 95% 100% 100% 7. Operational Audit: Monthly audit of three operational indicators from CPS contract. Rx 100% 100% Target: Actual: 100% 100% 100% 100% 100% 100% 100% 100% Psychology Responsible Party: Arthur DiRocco, Ph.D. I. Measure Name: Outpatient Readiness Scale (ORS)