MAJOR DEPRESSV DISORD, RECURRENT, SEVERE W/O PSYCH FEATURES 1 1 MAJOR DEPRESSV DISORD, SINGLE EPSD, SEVERE W PSYCH FEATURES 1 1 DEPRESSV DISORDER, RECURRENT, SEVERE W/PSYCH FEATURES 1 1 2 DEPRESSV DISORDER, RECURRENT, UNSPECIFIED 1 1 2 EPISODE W/O PSYCHOTIC SYMPTOMS, UNSPECIFIED 1 1 MILD COGNITIVE IMPAIRMENT, SO STATED 1 1 OTH DISORDER NOT DUE TO A SUB OR KNOWN PHYSIOL COND 1 1 PATIENT ADMISSION DIAGNOSIS 2Q16 3Q16 4Q16 1Q17 TOTAL DEPRESSIVE EPISODES 1 1 SCHIZOPHRENIA 2 2 PARANOID SCHIZOPHRENIA 1 4 4 9 PARANOID SCHIZOPHRENIA-UNSPEC 0 POSTTRAUMATIC STRESS DISORDER-UNSPEC 2 3 3 1 9 PSYCHOSIS NOS 0 RECURRENT DEPRESSIVE DISORDER-PSYCHOTIC 0 SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE 14 14 12 8 48 SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TYPE 2 1 3 SCHIZOAFFECTIVE DISORDER, UNSPECIFIED 6 3 2 4 15 SCHIZOPHRENIA, UNSPECIFIED 9 14 11 11 45 UNSP PSYCHOSIS NOT DUE TO A SUB OR KNOWN PHYSIOL COND 11 8 4 6 29 UNSPECIFIED MOOD DISORDER (AFFECTIVE) 1 3 4 Admissions 59 65 51 53 228 Admitted with primary diagnosis of mental retardation, traumatic brain injury, dementia, substance abuse or dependence. 1.7% (1) 1.5% (1) 0% (0) 1.9% (1) 1.3% (3) Peer Supports
Staff will receive initial and ongoing education training in the hospital approved Behavior Management Program and Recovery in Action to assist in establishing therapeutic relationships, so when a crisis begins, staff will be more influential and effective in preventing the use of seclusion and restraint. Staff development will provide ongoing education to reinforce the organization’s commitment to ensuring a caring, respectful, therapeutic environment. Data gathered through hospital performance measures will be analyzed to determine progress. V24) Riverview certifies that 95% of professional staff have maintained continuing education credits and have received the ten hours of annual required by ¶216; DATE TITLE PRESENTER 1Q2016 4 July – September 2015 2Q2016 19 October – December 2015 3Q2016 14 January – March 2016 4Q2016 21 April – June 2016 7/7/2016 1 Learning Mediated by Misconceptions and Engaging Presenters Steven Macchione, Psych Intern 7/14/2016 1 East Meets West Part I: Cultural Issues Working with Persons of Asian Indian Origin TG Sriram, MD 7/21/2016 1 East West Part II: Mental Health Insights from Ancient Indian Literature TG Sriram, MD 7/28/2016 1 The Case of Mr. CG: A presentation of competency restoration Graham Danzer, Intern 8/4/2016 1 Treatment Team Planning Stephanie George-Roy, LSW Janet Barrett, CTRS 9/8/2016 1 Physical findings and Underlying Conditions: Things to be looked at John MD 9/22/2016 1 Mr. Nervous: AKA the Walking Cluster C Brooke Hoffman, PsyD 9/29/2016 1 Some historical facts re: AMHI and chronic, persistent mental illness over the past quarter century George Davis, MD V25) Riverview certifies that staffing ratios required by ¶202 are met, and available documentation that shows actual staffing for up to one recent month; Type Consent Decree Ratio General Medicine Physicians 1:75
The record includes a special sheet that has been filled out to document reason for seclusion, description of behavior and the lesser restrictive alternatives considered. 85% 100% The record reflects that the patient was released, unless clinically contraindicated, at least every 2 hours or as necessary for eating, drinking, bathing, toileting or special medical orders. 85% 100% Reports of seclusion events were forwarded to Clinical Director and Patient Advocate. 90% 100% 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% 98% there was a PRN order, there is evidence that physician was counseled. 95% 100%
Liberty Healthcare – Hours Coverage Dr. Judy Burk Acting Clinical Director All indicators exceeded standards. Liberty Healthcare – Physician Staffing Dr. Judy Burk Acting Clinical Director All indicators met or exceeded standards. Main Security Surveillance Richard Levesque Director of Support Services All indicators met standards. Maine General Community Care/HealthReach Dr. Judy Burk Acting Clinical Director All indicators met standards. Maine General Medical Center Laboratory Services Dr. Judy Burk Acting 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 All indicators met or exceeded standards. Medical Staffing and Services of Maine Dr. Judy Burk Acting Clinical Director All indicators met standards. Motivational Services Dr. Judy Burk Acting 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. Otis Elevator Richard Levesque Director of Support Services All indicators met standards. Pine Tree Legal Assistance Dr. Judy Burk Acting Clinical Director No services were provided during this timeframe. Project Staffing Michaud Business Services Manager All indicators exceeded standards. Protection One Richard Levesque Director of Support Services No services were provided during this timeframe. Securitas Security Services Philip Tricarico Safety Compliance Officer All indicators met or exceeded standards. UniFirst Corporation Richard Levesque Director of Support Services Two indicators did not meet standards. Linen received clean & neat in appearance at the hospital; and, Infection control measures taken at the provider’s
Hand Hygiene Compliance Actual Data: Upper Saco Meds – 100% Upper Kennebec Meds –100% Upper Saco Milieu 7AM-7PM – 100% Upper Kennebec Milieu 7AM-7PM – 100% Upper Saco Milieu 7PM-7AM – 100% Upper Kennebec Milieu 7PM-7AM – 100% Lower Kennebec Meds – 90% Lower Saco Meds – 100% Lower Kennebec Milieu 7AM-7PM – 100% Lower Saco Milieu 7AM-7PM –100% Lower Kennebec Milieu 7PM-7AM – 100% Lower Saco Milieu 7PM-7AM – 100% Plan: Continue to monitor and measure. III. Measure Name: Assisting Patients with Hygiene Measure Description: Staff offer hand gel to patients prior to breakfast, lunch, and dinner, ten (10) days per month. Measure Type: Quality Assurance Results Unit Baseline 1Q2016 2Q2016 3Q2016 4Q2016 YTD Target Employee Hand Hygiene Compliance 88% FY 2016 >90% >90% >90% >90% >90% Actual 98% 98% Data: The mean compliance rate for July 2016 is 97%. The mean compliance rate for August 2016 is 98%. The mean compliance rate for September 2016 is 100%. Plan: Continue to monitor and measure. Medication Errors and Adverse Reactions
Dose 10 Omission 44 Wrong Dose 8 Wrong Time 7 79 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% 2. Controlled Substance Loss Data: Monthly CII Safe Vendor Receipt Report. Rx 0 0 Target: 0 Actual: 0 0 0 3. Controlled Substance Loss Data: Monthly Pyxis Controlled Drug Discrepancies. All 0/mo Target: 0 Actual: 0 0 0 (0/mo) 4. Medication Management Monitoring: Measures of drug reactions, adverse drug events, and other management data. Rx 10/year Target: 0 Actual: 0 0 10 5. Medication Management Monitoring: Resource Documentation Reports of Clinical Interventions. Rx 136/ quarter 100% Target: Actual: 100% 167 6. Psychiatric Emergency Process: Monthly audit of all psych emergency measures against 8 criteria. All 100% 100% Target: Actual: 100% 100% 7. Operational Audit: Rx 100% 100% Target: Actual: 100% 100%
Measure Description: Admittance of all NCR patients within 24 hours of referral Type of Measure: Quality Assurance Results Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD Target NCR referrals admitted within 24 hours N/A 100% 100% 100% 100% 100% Actual 100% 4/4 100% 4/4 Data Analysis: There were 4 NCR admissions this quarter. All were admitted the day of referral. Action Plan: Continue to gather data on wait days for NCR admissions. Keep one bed available on the Forensic unit for NCR admissions at all times. July 2016 August 2016 September 2016 1Q2017 # of NCR Admissions 1 0 3 4 Average Wait Days 0 0 0 0 II. Measure Name: Jail Transfer Bed Measure Description: Keep one Jail Transfer bed open and track length of stay and legal outcomes. Type of Measure: Performance Improvement July 2016 August 2016 September 2016 1Q2017 # of Jail Transfer Admissions 0 0 0 0 # of Jail Transfer Discharges 1 0 0 1 Data Analysis: There were no Jail Transfers admitted this quarter. Currently unable to have an open bed designated for jail transfers due to the large number of court ordered forensic patients. Action Plan: Continue to track data and keep one bed available for jail transfers. III. Measure Name: Off PA Admission Paperwork
Records will be completed within Joint Commission standards, state requirements, and Medical Staff bylaws timeframes. 55 charts for patients released during the quarter were reviewed. ALL of the charts were completed within the required timeframe. 100% 80% Discharge summaries will be completed within 15 days of discharge. 55 out of 55 discharge summaries were completed within 15 days of discharge. 100% 100% All to be placed in the medical record will be approved by the Medical Records Committee. 6 revised forms, 1 deleted form in the first quarter. 100% 100% Medical transcription will be timely and accurate. 895 dictated reports were completed within 24 hours. 100% 90% Summary: The indicators are based on the review of all discharged records. There was 100% 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. Confidentiality: Indicators 1Q2017 Findings 1Q2017 Compliance Threshold Percentile All patient information released from the Health Information Department will meet all Joint Commission, State, Federal & HIPAA standards. 2,686 requests for information (216 requests for patient information and 2,470 police checks) were released. 100% 100%
Pregnancy test Sodium Ammonia Pregnancy Test Electrolytes Pregnancy Test Serum Levels At steady 3-6 months As clinically indicated At steady state As clinically indicated Two levels to establish dose, 4 weeks apart As clinically indicated Longitudinal Monitoring 3 months Once At 3months: BUN SCr TSH Every 3 months for the 1st year of therapy: Weight CBC LFTs Albumin Sodium Monthly for 3 months: CBC LFTs Albumin Electrolytes BUN SCr Every 6 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 Results Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD Target Laboratory Parameters 79% (FY2016) 90% 90% 90% 90% 90% Actual 60% 81%
Baseline Sept 2013 2Q2016 3Q2016 4Q2016 1Q2017 Goal Oct 2015 Nov 2015 Dec 2015 Jan 2016 Feb 2016 Mar 2016 Apr 2016 May 2016 June 2016 July 2016 Aug 2016 Sept 2016 Nursing Mandates 14 11 8 10 11 8 10 11 8 10 1 0 0 0 Mental Health Worker (MHW) Mandates 49 62 41 32 62 41 32 62 41 32 6 10 6 0 Nursing mandates increased from 12 last quarter to 1 this quarter. MHW mandates decreased from 131 last quarter to 22 this quarter. Nursing Department Chart Review Effectiveness 1Q2017 - Lower Saco Indicators Findings Compliance GAP note written in appropriate manner at least every 24 hours 12 of 15 80% STGs/ Interventions relate directly to content of GAP note 13 of 15 87% Weekly Summary note completed 9 of 15 1 n/a 67% Diabetes education Teaching checklist shows documentation of client teaching (diabetic clients) 1 of 15 9 n/a 67% Multidisciplinary Teaching checklist active being completed 14 of 15 1 n/a 100% Dental education Teaching checklist 9 of 15 60% Nursing Assessment of Suicide risk being completed with Treatment Plan review 15 of 15 100%