hours of inpatient care. One patient accounted for more than half of these hours of seclusion. Riverview has initiated 12 new courses in recovery focused patient care for staff. 4 Clinical Case Conferences have focused on the Recovery Model and care. The hospital has a Recovery Training Specialist to provide training and services to staff. Riverview is a “trauma informed” hospital that works with patients who have experienced many types of trauma in their lives. At intake, all patients complete a questionnaire regarding trauma and history. During New Hire CONSENT DECREE Recommendation Quality Improvement Measure Actions Taken During the Quarter Orientation, all are trained in competencies regarding Trauma and Recovery in order to provide the most appropriate level of care. 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 in working with class members with challenging behaviors. 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 reported in the Quarterly Report. The hospital holds a clinical education conference every Thursday at noon. Staff from across all disciplines at the hospital are welcome to participate. 6 patient specific Clinical Case Conferences have been held since January. 4 Recovery Model specific Clinical Conferences have been held since January. 4 Allied Health Clinical Case Conferences on Spirituality, Cultural Differences, Encountering the Other and Compassion Fatigue have been held since January. The conferences include staff from all disciplines at Riverview and when
appropriate participation from faculty at Geisel Medical School at Dartmouth College. Efforts should be initiated to intensify the opportunities offered to class members on the Forensic Units in order to increase their social skills and their knowledge and performance competencies about subjects of interest to them. Patient Individualized Treatment will contain documentation of participation in all treatment activities. Treatment Team Coordinators will conduct daily chart audits to ensure documentation. Treatment mall change every thirteen weeks. Prior to the new schedule being developed group ideas are requested from patients at the community meetings held on the units. Although specifically not identified with a Trauma label, Psychology and Social Work offer groups that focus on a variety of trauma issues. The CONSENT DECREE Recommendation Quality Improvement Measure Actions Taken During the Quarter titles of the groups are kept discreet to protect the patients in these groups from being stigmatized. Efforts should be initiated to intensify the opportunities offered to class members on the Forensic Units in order to increase their social skills and their knowledge and performance competencies about subjects of interest to them. Patient Individualized Treatment Plans will contain documentation of participation in all treatment activities. Treatment Team Coordinators will conduct daily chart audits to ensure documentation. Treatment mall groups change every thirteen weeks. Prior to the new schedule being developed group ideas are requested from patients at the community meetings held on the units. Although specifically not identified with a Trauma label, Psychology and Social Work offer groups that focus on a variety of trauma issues. The titles of the groups are kept discreet to protect the patients in these groups from being stigmatized. Riverview should be managed as a single Hospital and the exclusion of Lower Saco from the federal Medicaid program should be reconsidered as an urgent priority. Completed in November 2014. In 2013, the hospital was bifurcated in an effort to meet CMS requirements for certification. A decision was made in November 2014 that this separation interfered with the delivery of high quality services at the hospital. Instead of operating two hospitals in one building
if necessary, by an independent clinical consultant, to The first part of the evaluation consisted of testing the competency of staff in demonstrating knowledge and a CONSENT DECREE Recommendation Quality Improvement Measure Actions Taken During the Quarter determine whether sufficiently individualized interventions are being designed and consistently implemented to replace unacceptable behavior with appropriate alternative behaviors. ability of MOAB techniques. The consistently were unable to demonstrate MOAB techniques. However they quite easily demonstrated NAPPI techniques. It is important to note: The fact that staff reverted back to skills they had learned over many years of practice (NAPPI) is not unusual in this case. Through repetition and practice, motor skills become automatic. The brain in essence “hardwires” the skills into memory. The key is to replace those “muscle memories” with new memories (skills) through the repetition and practice of new skills and/or techniques. Riverview is providing consistent on-going instruction by providing annual MOAB recertification training and skills drills to improve staff competency through opportunities to develop new muscle memories to replace those acquired through NAPPI training. The second part of the evaluation consisted on reviewing six videos of patient related events on the term
CONSENT DECREE Recommendation Quality Improvement Measure Actions Taken During the Quarter Work continues in recruiting for all positions. New positions were funded in the last legislative session and are being filled. The hospital continues to be challenged by trained employees who leave for other state positions which are of less intensity. A recent change in the staffing model has been implemented and is an enormous step in moving toward unit based staffing. An overall of the staffing plan was completed in an effort to “even out” staff scheduling. The hospital hired a new Director of Nursing during the past quarter who is addressing nursing staffing needs. The use of "float" staff, especially those recently hired at Riverview, requires review in order to reduce the likelihood of risk due to unfamiliarity with and knowledge of the individuals with challenging behaviors or the need for specialized interventions. This review is especially critical for any assignment to the Forensic Units. 100% of new on acute units will have received and passed competency based skills training before being assigned. The Director of Nursing is currently reviewing staffing models to be used in the hospital. In 2015, the hospital will move to a unit-based staffing model to enhance the continuity of care for all patients. To make the staffing model effective the hospital has initiated: Restructured orientation for unit staff – The new plan is to have nurse educator work with the Staff Development office to have all staff receive full orientation before they work on any unit, in order to improve safety for patients and staff alike. Mentoring of new staff by experienced personnel – The Nurse Educator and Nurse Managers will implement a preceptorship program.
Amistad Peer Support Services Robert J. Harper Superintendent All indicators met standards. Community Dental, Region II Dr. Brendan Kirby Clinical Director All indicators met or exceeded standards. Comprehensive Pharmacy Services Dr. Brendan Kirby Clinical Director All indicators met standards. Comtec Security Richard Levesque Director of Support Services All indicators met or exceeded standards. Cummins Northeast Richard Levesque Director of Support Services All indicators met standards. Dartmouth Medical School Robert J. Harper 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 All indicators met standards. Goodspeed & O’Donnell Dr. Brendan 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 Clinical Director All indicators met standards. Main Security Surveillance Richard Levesque Director of Support Services 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 All indicators met standards. COMMISSION Contractor Program Administrator Summary of Performance MD-IT Transcription Service Michelle Welch Acting 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. Brendan Kirby Clinical Director All indicators met standards. Motivational Services Dr. Brendan Kirby 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.
Within 1 STDV of the Mean Hospital Associated Infection Rate FY 2014 1 STDV within the mean 7 HAI/IC Rate 1.1 4 HAI/IC Rate 0.83 12 HAI/IC Rate 1.7 6 HAI/ 1 CAI Actual Outcome 1 STDV within the mean 1 STDV within the mean A Hospital Acquired Infection (HAI) is any infection present, incubating or exposed to more than 72 after admission (unless the patient is off hospital grounds during that time) or declared by a physician, a physician’s assistant or advanced practice nurse to be a HAI. A Community Acquired Infection (CAI) is any infection present, incubating or exposed to prior to admission; while on pass; during off-site medical, dental, or surgical care; by a visitor, any prophylaxis treatment of a condition or treatment of a condition for which the patient has a history of chronic infection no matter how long the patient has been hospitalized; or declared by the physician, physician’s assistant, or advanced practice nurse to be a community acquired infection. An Idiosyncratic Infection is any infection that occurs admission and is the result of the patient’s action toward himself or herself. JOINT COMMISSION Infections: Lower Kennebec: Urinary Tract Infection Lower Saco: Pneumonia (CAI) Lower Saco SCU: Nickel size wound on left leg Upper Saco: Bladder Infection Folliculitis of Chest Upper Kennebec: Left great toe infection x2 H Pylori Frequent Metastatic Breast Cancer lesions Data Analysis: Total Infections: 8
HAI: 7 CAI: 1 Idiosyncratic Infections: 0 Patient Days: 7854 Plan: Ongoing surveillance JOINT COMMISSION II. Measure Name: Employee Hand Hygiene Rate Measure Description: Staff will observe the hand hygiene practice of nurses as they pass medications. (10 observations per month) will do ten (10) hand hygiene observations per month (before & after patient contact) in the milieu on the 7-3 shift. Staff will do ten (10) hand hygiene observations per month (before & after patient contact) in the milieu on the 3-11 shift Measure Type: Performance Improvement Results Unit Baseline 1Q2016 2Q2016 3Q2016 4Q2016 YTD Target Employee Hand Hygiene Compliance 80% FY 2015 >90% >90% >90% >90% >90% Actual 95% 98%* (December 2015 only) 97 Data: Saco Meds – no data Upper Kennebec Meds –100% Upper Saco Milieu 7-3 – no data Upper Kennebec Milieu 7-3 – 100% Upper Saco Milieu 3-11 – no data Upper Kennebec Milieu 3-11 – 100% Lower Kennebec Meds – 100% Lower Saco Meds – 100% Lower Kennebec Milieu 7-3 – 98% Lower Saco Milieu 7-3 – 100% Lower Kennebec Milieu 3-11 – 85% Lower Saco Milieu 3-11 – 100% Infection Control Nurse – position vacant *Note: The Infection Control Nurse position was vacated in November 2015. Hand Hygiene data was only available for December 2015 for 3 of the 4 patient units. Data will be provided in the next quarterly report.
11/13/2015 Y OMISSION N N N US 2 1 3 12/4/2015 N EXTRA DOSE N N N US 1 0 4 12/29/2015 N DOSE Y N N LSS 1 0 3 Totals: 40 22 9 1 LS: 23 US: 25 LK: 35 UK: 5 Percent 45% 88 Total Errors 25% 10% 1% 26% 28% 40% 6% *Each dose of medication is documented as an individual variance (error) Type of Error # of Errors Extra Dose 15 Omission 40 Dose 11 Wrong Drug 4 Wrong Form 11 Wrong Time 6 Wrong Route 1 JOINT COMMISSION Dispensing Process Measure Unit Baseline 2014 Goal 3Q 2015 4Q 2015 1Q 2016 2Q 2016 1. Controlled Substance Loss Data: 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 Pyxis Controlled Drug discrepancies. All 0/mo 0 Target: Actual: 0 0 (0/ mo) 0 0 (0/ mo) 0 0 (0/ mo) 0 0 (0/ mo) 4. Medication Management Monitoring: Measures of drug reactions, adverse drug events and other management data. Rx 8/year 0 Target: Actual: 0 2 0 3 0 0 0 0 5. Medication Management Monitoring: Resource Rx 99/ quarter 100% Target: Actual: 100% 73 100% 56 100% 31 100% 144
STRATEGIC PERFORMANCE EXCELLENCE Areas/Groups Monitored N = Numerator D = Denominator JUL 2015 AUG 2015 2015 OCT 2015 NOV 2015 DEC 2015 JAN 2016 FEB 2016 MAR 2016 APR 2016 MAY 2016 2016 Patient Care # of radios Job Coach/1 1/ 1* 1/ 1 1/ 1* 1/ 1 1/ 1* 0/ 1** OPS/2 2/ 2* 2/2 1/ 2*1 2/ 2 2/ 2* 2/2 Tx Mall, Clinic, Dietary, Med Rec/5 5/ 5* 5/ 5 3/ 5*2 5/ 5 5/ 5* 4/ 5*5 US, UK, LS, LSSCU, LK, LKSCU/10 9/ 10 10/ 10 8/ 10*3 10/ 10 7/ 10*3 9/ 10 Support Services/ # of radios Administration/3 3/ 3* 3/ 3 3/ 3 3/ 3 3/ 3* 3/ 3 Housekeeping/ 10 9/ 10** 10/ 10 9/ 10*3 9/ 10*1 10/ 10* 10/ 10 Maintenance/14 14/ 14* 14/ 14 12/ 14*4 14/ 14 14/ 14* 14/ 14 NOD/1 1/1 1/1 1/1 1/1 0/ 1*4 1/ 1* Nursing Services/1 1/ 1* 1/ 1 0/ 1*5 0/ 1*2 1/ 1* 0/ 1*6 Operations/1 1/1 1/1 1/1 1/1 1/1 1/1 Security/4 4/4 4/4 4/4 4/4 4/4 4/4 State Forensic Services/1 1/ 1* 1/ 1 0/ 1*6 1/ 1 1/ 1* 0/ 1*7 Patient Care Areas 17/ 18 18/ 18 13/ 18 18/ 18 15/ 18 18/ 18 Support Services 34/ 35 32/ 35 30/ 35 33/ 35 34/ 35 32/ 35 Total 51/ 53 53/ 53 43/ 53 51/ 53 49/ 53 53/ 53
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 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 hospital wide processes. Currently the following performance improvement teams involving medical staff are in existence or have recently completed their reviews: Review of treatment plans Lower Saco Unit 4. Miscellaneous Performance Improvement Activities: In addition to the formal monitoring and peer review activities described above, the Clinical Director is vigilant for methods to improve the delivery of clinical care in the hospital from interactions with, and feedback from, other discipline chiefs, from patients or from their complaints and grievances, and from community practitioners who interact with hospital medical staff. These interactions may result in reports to the Medical Executive Committee, in the creation of performance improvement teams, performance of a root-cause analysis, or counseling of individual practitioners. 5. Reports of Practitioner-specific Data to Individual Practitioners: The office of the Clinical Director will provide confidential outcomes of data to each medical staff member within 30 days of the end of the fiscal year. This information will be available without the necessity of the practitioner requesting it. It will be placed in the confidential section of the practitioner’s medical staff file and freely accessible during normal business hours. The office of the Clinical Director will notify all medical staff members when the data is available for review. Each medical staff member may discuss the data with the Clinical Director at any time. 6. Process to amend the quality improvement plan, including adding or deleting any monitors or processes:
debriefing completed within 24 hrs of coercive event 15 n/a 100% STRATEGIC PERFORMANCE EXCELLENCE Nursing Department Initial Chart Compliance 2Q2015 – All Units Indicators Findings Compliance GAP note written in appropriate manner at every 24 hours 51 of 60 85% STGs/ Interventions relate directly to content of GAP note. 58 of 60 97% Weekly Summary note completed. 27 of 60 45% Diabetes education Teaching checklist documentation of patient teaching (diabetic patients) 3 of 60 52 n/a 92% Multidisciplinary Teaching checklist active being completed. 57 of 60 1 n/a 97% Dental education Teaching checklist 52 of 60 1 ref., 1 n/a 90% Nursing Assessment of Suicide risk being completed with Treatment Plan review 58 of 60 1 loc 98% Annual Assessment completed. 40 of 60 5 n/a 75% Patient’s rights signed. 41 of 60 4 loc., 3 ref. 80% Treatment Plan Reviewed/Modified Every 2 Weeks 50 of 60 4 n/a 90% Informed Consent signed and dated 35 of 60 4 loc., 2 ref. 68% STG Interventions are clear, simple behavioral actions for nurses 51 of 60 9 n/a 100% STG for patient is behavioral and measurable 44 of 60 9 n/a 88% SRC monitor sheets completed 1 of 60 58 n/a 98% Patient debriefings completed w/in 24 hours after episodes of HOH/SRC/Restraints 1 of 60 58 n/a 98% Safety meeting held 72 hours after coercive event 1 of 60 58 n/a 98% Treatment plan updated after every coercive event 58 n/a 97%