Leadership met on Friday, March 6th to review the corrective action steps outlined in the hospital’s response. Recommendation Quality Improvement Measure Actions Taken During the Quarter Prior to his/her treatment team meeting, the class members should be provided the opportunity to meet with a peer specialist in order to prepare for the discussion and to clearly outline any preferences for treatment or discharge planning. approaches to treatment, including employment, should be consistently explored with and offered to class member, despite disinterest or refusal at the time of admission. Treatment Team Coordinators will document all patient engagement in preparation for Treatment Team meetings. The daily chart audit form used by Treatment Team Coordinators/Auditors will be updated by Medical Records to reflect which patients received pre-treatment team meeting engagement. Treatment Team Coordinators developed & use an audit tool on each record as it is reviewed / revised the day of the team meeting. TTCs handout to the patient, the ‘Your is Essential” form 2-3 days prior to the meeting and offer to assist the patient to complete the form (if needed) prior to the meeting. The form is attached to the treatment plan. If patient refuses to complete the from, this is noted on the form and signed by the staff. Riverview's leadership should take immediate steps to ensure that the principles of the Recovery model are clearly defined, articulated, and supported throughout each of the four units. 100% of patient records will include documentation of the patient's into their individualized treatment plan and that the input was used during the Treatment Team meeting. Staff orientation has increased focus on the principles of recovery. As part of this effort staff are encouraged to support patients with making their needs, goals and life expectations made know. Where appropriate and in consistency with the TP, the patients’ comments are incorporated into treatment planning activities. CONSENT DECREE Recommendation Quality Improvement Measure Actions Taken During the Quarter Riverview's clinical leadership should work with nursing and Mental Health Worker staff to design and implement case conferences or Grand Rounds so that there is greater knowledge, skills, and support The list of case conferences and Grand Rounds will be maintained. The roster of staff participation will be maintained by the Staff and Organizational Development Office. These data will be Clinical case conference occurs regularly on Thursdays at 12 noon. In addition, longer audiovisual conferences with faculty at Dartmouth College three times per year and will move to a similar Thursday noon slot for the
Measure Unit Baseline 2014 Goal 2Q 2015 3Q 2015 4Q 2015 1Q 2016 1. Controlled Substance Loss Data: Daily Pyxis-CII Safe Compare Report. All 0.875% 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: Actual: 0 0 0 0 0 0 0 0 3. Controlled Substance Loss Data: Monthly Controlled Drug discrepancies. All 22/mo 0 Target: Actual: 0 66 (22/ mo) 0 42 (14/ mo) 0 37 (12/ mo) 0 22 7/ mo 4. Medication Management Monitoring: Measures of drug reactions, adverse drug events and other management data. Rx 8/year 0 Target: Actual: 0 1 0 2 0 3 0 0 5. Medication Management Monitoring: Resource Documentation Reports of Clinical Interventions. Rx 99/ quarter 100% Target: Actual: 100% 79 100% 73 100% 56 100% 31 6. Psychiatric Emergency Process: Monthly of all psych emergencies measures against 9 criteria. All 100% 100% Target: Actual: 100% 95% 100% 93% 100% 94% 100% 78% 7. Operational Audit: Monthly audit of 3 operational indicators from CPS contract. Rx 100% 100% Target: Actual: 100% 100% 100% 100% 100% 100% 100% 100% 1Q2016: 6. One psych emergency (PE) was reported during the quarter. Two of the nine criteria were not met: MAR/s printed/brought to unit by RPh and PH checking new MARs vs. updated MARs completing by nursing & reconciliation performed. The PE ended over the weekend and it is unclear if the protocol was followed. Re-education will be done to correct the process. JOINT COMMISSION Inpatient Consumer Survey
screens completed accurately 68.3% 41/60 Actual 68.3% 41/60 68.3% 41/60 Data Analysis: results indicate there is opportunity for improving the accuracy of the information gathered on the nutrition screen. The nutrition screen is completed by the nurse responsible for the admission. Action Plan: Determine similarities within the incomplete nutrition screens. Provide proper training to the nurses responsible for completing the nutrition screen upon admission. Identify the diagnoses on the nutrition screen that have common inaccuracies. STRATEGIC PERFORMANCE EXCELLENCE III. Measure Name: Hand Hygiene Compliance Measure Description: Supervisory staff: including the Food Service Manager and Cook III’s, will observe all dietary employees, as they return from break, for proper hand hygiene. Type of Measure: Performance Improvement Results Unit Baseline 1Q2016 2Q2016 3Q2016 4Q2016 YTD Target Percent of Dietary employees washing hands after break FY 2015 97.7% 338/346 90% 95% Actual 96.3% 343/356 96.3% 343/356 Data Analysis: The results of this quarter remain above 90%. This measure began as a performance improvement indicator in the first quarter of FY13 with 58% compliance. By the third quarter of FY15 the compliance rate had risen to above 90% and remains there. Action Plan: Continue to have line supervisors monitor handwashing compliance after breaks. Provide hand hygiene training annually Encourage front line supervisors to promote hand hygiene with their staff throughout the day.
Target Each patient receiving OT services has an MD order FY 2015 97% 100% 100% 100% 100% 100% Actual 100% 25/25 100% 25/25 Data Analysis: In review of Occupational Therapy Services Log all patients referred for services from July 1st to September 30, 2015 had both the referral sheet completed as well at the doctor’s order attached to it. Action Plan: Reviewed the results of the audit with Occupational Therapy staff and reviewed with staff the licensing standard that references not beginning Rehab. Services without an MD order. STRATEGIC PERFORMANCE EXCELLENCE II. Measure Name: Vocational Services Documentation Measure Description: Improving health outcomes/patient care. In order to receive effective treatment, all patients engaged in the Vocational Rehabilitation Program will have updated treatment plans and weekly documentation on the progress towards addressing the intervention outlines in the treatment plan. Methodology: Each quarter Rehabilitation Services Director will audit the charts of the patients involved in the Vocational Rehabilitation Program to review treatment plans and progress notes to ensure they are being completed in a timely manner and updated on a regular basis. The numerator will be the number of patient charts with the required documentation and the denominator will be the total number of patients in the Vocational Rehabilitation Program. Goal: To achieve and maintain an overall goal of 100% for 4 consecutive Quarters Type of Measure: Performance Improvement Results Unit 1Q2016 2Q2016 3Q2016 4Q2016 YTD Target Each patient working in the Voc. Rehab. Program has required documentation 60% 100% 100% 100% 100% 100% Actual 50% 6/12 50% 6/12 Data Analysis: