IMPULSE CONTROL DISORDER 1 1 2 DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED 1 3 1 5 MAJOR DEPRESSV DISORD, RECURRENT, SEVERE W/O PSYCH FEATURES 1 1 PATIENT ADMISSION DIAGNOSIS 4Q2016 1Q2017 2Q2017 3Q2017 TOTAL MAJOR DEPRESSV DISORD, SINGLE EPSD, SEVERE W/O PSYCH FEATURES 1 1 DEPRESSV DISORD, SINGLE EPSD, SEVERE W/PSYCH FEATURES 1 1 MAJOR DEPRESSV DISORDER, RECURRENT, UNSPECIFIED 1 1 1 3 MANIC EPISODE W/O PSYCHOTIC SYMPTOMS, UNSPECIFIED 1 1 MILD COGNITIVE IMPAIRMENT, SO STATED 1 1 MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION, UNSP 1 1 BIPOLAR DISORDER 1 1 PARANOID PERSOANLITY DISORDER 1 1 PARANOID SCHIZOPHRENIA 4 4 4 3 15 PERSONALITY CHANGE DUE TO KNOWN PHYSIOLOGICAL CONDITION 2 2 PERSONALITY DISORDER, UNSPECIFIED 1 1 POSTTRAUMATIC STRESS 3 1 4 1 9 RESIDUAL SCHIZOPHRENIA 1 1 SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE 12 8 12 11 43 SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TYPE 1 1 1 3 SCHIZOAFFECTIVE DISORDER, UNSPECIFIED 2 4 8 5 19 SCHIZOPHRENIA, UNSPECIFIED 11 10 7 10 38 SCHIZOPHRENIAFORM DISORDER 1 1 UNDIFFERENTIATED SCHIZOPHRENIA 1 1
3Q2017: 1. One report was completed within the 10 day timeframe. 3. Annual Reports are completed. Staffing and Staff Training V23) Riverview performance data shows that 95% of direct care staff have received 90% of their annual training. Indicators 1Q2017 2Q2017 3Q2017 4Q2017 YTD 1. Riverview and Contract staff will attend CPR training 81% 65/80 89% 59/66 94% 61/65 88% 185/211 2. Riverview and Contract will attend Annual training. 75% 135/179 47% 28/60 56% 24/43 66% 187/282 3. Riverview and contract staff will attend MOAB training 66% 52/79 68% 74/109 See below 67% 126/188 3Q2017: All staff members that are out of compliance have been notified. All staff members that are out of compliance have been notified. In January, 77 staff have been trained in the new program, as they have become due for the former MOAB program Responsible Party: Susan Bundy, Director of Staff Development I. Measure Name: Ongoing Education and Training Measure Description: HR.01.05.03 requires that staff will participate in ongoing education and training to increase and maintain their competency. Type of Measure: Performance Improvement Goal: 90% of direct support staff will attend Collaborative Pro Active Solutions training by June 2017. Attendance will be tracked by Staffing and Organizational Development. Progress will be reported quarterly. Progress: As of March 20, 2017, 149 employees have received Collaborative Pro-Active Solutions training.
Manual Hold Mechanical Restraint Locked Seclusion Grand Total % of Total Cumulative % MR2951 90 70 160 64.00% 64.00% MR7878 17 16 33 13.20% 77.20% MR7950 8 2 10 4.00% 81.20% MR684 8 8 3.20% 84.40% MR7419 3 3 6 2.40% 86.80% MR4974 5 5 2.00% 88.80% MR2576 2 2 4 1.60% 90.40% MR4814 3 3 1.20% 91.60% MR7127 2 1 3 1.20% 92.80% MR7932 2 1 3 1.20% 94.00% MR91 1 1 2 0.80% 94.80% MR484 1 1 2 0.80% 95.60% MR8023 2 2 0.80% 96.40% MR6466 1 1 0.40% 96.80% MR7032 1 1 0.40% 97.20% MR7326 1 1 0.40% 97.60% MR7468 1 1 0.40% 98.00% MR7509 1 1 0.40% 98.40% MR7820 1 1 0.40% 98.80% MR7892 1 1 0.40% 99.20% MR8016 1 1 0.40% 99.60% MR8022 1 1 0.40% 100.00% 153 0 97 250 100.00% 27% (22/81) of the average hospital population experienced some form of confinement event during 3Q2017. Five of these patients (6% of the average hospital population) accounted for 87% of the confinement events. V28) Riverview demonstrates that, on a review of two quarters of data, for 95% of seclusion events, seclusion was employed only when absolutely necessary to protect the patient from causing physical harm to self or others or for the management of violent behavior;
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 two 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% 100% Where there was a PRN order, there is evidence that physician was counseled. 95% N/A Confinement Events Management 3Q2017 Mechanical Restraint Events (0) Events
Mechanical Services Richard Levesque Director of Support Services All indicators met or exceeded standards. Medical Staffing and Services of Maine Dr. Joanna Gratton Clinical Director All indicators met standards. Norris Richard Levesque Director of Support Services No services were provided during this timeframe. Occupational Therapy Consultation and Rehabilitation Services 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 Indicator exceeded standards. Project Staffing Cindy Michaud Business Services Manager All indicators exceeded standards. Securitas Security Services Philip Tricarico Safety Compliance Officer All indicators met or exceeded standards. UniFirst Corporation Richard Levesque Director of Support Services One indicator did not meet standards: Infection Control Measures at the provider’s facility. All other indicators met standards. Waste Management Debora Proctor Executive Housekeeper All indicators met standards. Worldwide Travel Staffing Renee Pfingst Director of Nursing All indicators met standards. Adverse Reactions to Sedation or Anesthesia TJC PI.01.01.01 EP6: The hospital collects data on the following: adverse events related to using moderate or deep sedation or anesthesia. (See also LD.04.04.01, EP 2) Capital Community Clinic - Dental Clinic Dental Clinic Timeout/Identification of Patient Indicators 4Q2016 1Q2017 2Q2017 3Q2017 YTD National Patent Safety Goals Apr N/A July N/A Oct 100% 4/4 Jan N/A
Goal 1: Improve the accuracy of Patient Identification. 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 Dentist as well as the Dental Assistant. May N/A Aug N/A Nov N/A Feb N/A June N/A Sept 100% 7/7 Dec 100% 1/1 Mar 100% 3/3 Total N/A Total 100% 7/7 Total 100% 5/5 Total 100% 3/3 Dental Clinic Post Extraction Prevention of Complications and Follow-up Indicators 4Q2016 1Q2017 2Q2017 3Q2017 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 Apr N/A July N/A Oct 100% 4/4 Jan N/A 100% 15/15 May N/A Aug N/A Nov N/A Feb N/A June N/A Sept 100% 7/7 Dec 100% 1/1 Mar 100% 3/3 Total N/A Total 100% 7/7 100% 5/5 100% 3/3
No problems were found in 3Q2017 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 needs to be strictly adhered to requiring training, education, and policy development at all levels. Actions: The above indicators will continue to be monitored. Regulatory and Compliance Standards in Documentation Ensuring Fiscal Responsibility in Documentation and Billing Practices Indicator and Rationale for Selection 1Q2017 2Q2017 3Q2017 4Q2017 Identification Data 98% 54/55 100% 61/61 98% 66/67 Medical History, including complaint; HPI; past, social & family hx.; ROS, and physical exam w/in 24 hr. conclusion and plan 93% 55/55 4 Refused 100% 61/61 7 Refused 100% 67/67 11 Refused Summary of patient’s psychosocial as appropriate to the patients * 71% 39/55 16 > 7 days 82% 50/61 11 > 7 days 81% 54/67 13 > 7 days Psychiatric Evaluation in patient’s record w/in 24 hrs. of admission 95% 52/55 1 > 24 2 > 60 100% 61/61 93% 62/67 5 > 60 Physician (TO/VO w/in 72 hr.) 96% 151/157 98% 127/130 94% 128/135 Evidence of appropriate informed consent 100% 55/55 100% 61/61 100% 67/67 Clinical observations including the results of therapy. 100% 55/55 100% 61/61 100% 67/67 Nursing discharge Progress Note with time of discharge departure 95% 52/55 87% 53/61 84% 56/67 Consultation reports, when applicable 80% 99/123 100% 61/61 75% 190/253 Results of autopsy, when performed N/A N/A N/A Advance Directive Status on admission and SW follow up after 93% 51/55 87% 53/61 93% 62/67 Notice of Privacy 100% 55/55 100% 61/61 98% 66/67
Nursing Department Chart Review Effectiveness 3Q2017 Saco Indicators Findings Compliance Encounter note written between the hours of 0700-2300. 13/15 87% A shift assessment is completed each shift. 6/15 40% Weekly Summary note completed. 14/15 93% Observational note completed on patient who is on a higher level of observation i.e. ¼ hour checks or 1:1. 6/15 8 n/a 93% Diabetes teaching checklist active/completed (if patient is diabetic). 2/15 13 n/a 100% Multidisciplinary Teaching checklist active/completed. 14/15 93% Dental Education Teaching checklist active/completed. 15/15 100% Nursing Assessment of Suicide Risk being completed with Treatment Plan Review. 15/15 100% Annual Assessment completed. 6/15 9 n/a 100% Patient’s Rights reviewed and signed. 12/15 3 ref. 100% Informed Consent signed, dated and timed. 12/15 3 ref. 100% Number of Telephone Orders for the month. 20/20 100% Number of Telephone Orders signed by the prescriber within 24 hours. 20/20 100%
15 My complaints and grievances were addressed. 88% 63% 63% 66% 70% 16 I participated in planning my discharge. 88% 88% 57% 63% 74% 17 Both I and my doctor or therapists from the community were actively involved in my hospital treatment plan. 75% 38% 54% 50% 54% 18 I had an opportunity to talk with my doctor or therapist from the community prior to discharge. 60% 50% 55% 54% 55% 19 The surroundings and atmosphere at the hospital helped me get better. 65% 38% 56% 63% 56% 20 I felt I had enough privacy in the hospital. 60% 38% 58% 63% 55% 21 I felt safe while I was in the hospital. 65% 75% 63% 69% 68% 22 The hospital environment was clean and comfortable. 65% 88% 68% 69% 73% 23 Staff were sensitive to my cultural background. 69% 63% 67% 64% 66% 24 My family and/or friends were able to visit me. 75% 25% 67% 63% 58% 25 I had a choice of treatment options. 75% 38% 67% 63% 61% 26 My contact with my doctor was helpful. 70% 88% 65% 66% 72% 27 My contact with nurses and therapists was helpful. 75% 75% 71% 67% 72% 28 If I had a choice of hospitals, I still choose this one. 45% 50% 59% 68% 56% 29 Did anyone tell you about your rights? 88% 38% 69% 68% 66% 30 Are you told ahead of time of changes in your privileges, appointments, or daily routine? 69% 38% 61% 63% 58% 31 Do you know someone who can help you get what you want or stand up for your rights? 81% 88% 70% 71% 78% 32 My pain was managed. 69% 88% 68% 68% 73% Overall Score 68% 59% 64% 61% 63% Pharmacy Services Responsible Party: Michael Migliore, Director of Pharmacy I. Measure Name: Controlled Substance Loss Data Measure Description: Daily and monthly comparison of Pyxis vs CII Safe Transaction Report. Type of Measure: Quality Assurance