ATTENTION DEFICIT W/ HYPERACTIVITY 1 1 AUTISTIC DISORDER 1 1 BIPOLAR DISORD, CRNT EPISODE MANIC SEVER, W PSYCH FEATURES 1 1 BIPOLAR DISORD, CRNT EPISODE MANIC W/O PSYCH FEATURES, MILD 1 1 BIPOLAR DISORD, CRNT EPSD DEPRESS, SEVERE, W PSYCH FEATURES 1 3 4 BIPOLAR DISORDER, UNSPECIFIED 10 6 6 6 28 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, SEVERE, SPEC W/ PSYCHOTIC BEHAV 1 1 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, SEVERE, W/O PSYCHOTIC FEATURES 1 1 BIPOLAR I, REC EPIS OR CURRENT MANIC, IN PARTIAL OR UNSPEC REMISSION 1 1 BIPOLAR I, REC EPIS OR CURRENT MANIC, SEVERE, W/ PSYCHOTIC BEHAV 2 2 BIPOLAR II DISORDER 1 1 BORDERLINE PERSONALITY DISORDER 1 1 2 DELUSIONAL DISORDERS 1 1 2 DEMENTIA IN OTH DISEASES CLASSD ELSWHR W/ BEHAVIORAL DISTURB 1 1 2 DEPRESSIVE DISORDER NEC 3 3 DEPRESSIVE DISORDER-UNSPEC 1 1 IMPULSE CONTROL DISORDER 1 1 MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED 2 1 3 MAJOR DEPRESSV DISORD, RECURRENT, SEVERE W/O PSYCH FEATURES 1 1 DEPRESSV DISORD, SINGLE EPSD, SEVERE W PSYCH FEATURES 1 1 MAJOR DEPRESSV DISORDER, RECURRENT, SEVERE W/PSYCH FEATURES 1 1 2 MAJOR DEPRESSV DISORDER, RECURRENT, UNSPECIFIED 1 1 MILD COGNITIVE IMPAIRMENT, SO STATED 1 1
Contact during admission. (v8) 100% 64/64 100% 49/49 100% 64/64 100% 51/51 Community Integration/Bridging Inpatient & OPS. Inpatient OPS 100% 58 127 100% 91 131 100% 26 204 100% 21 221 Peer Support will make a documented attempt to have patients fill out a survey before discharge or annually to evaluate the effectiveness of the peer support relationship during hospitalization. 22% 14/63 41% 20/49 46% 30/65 19% 9/48 Grievances responded to on time by Peer Support, within 1 day of receipt. 100% 161/161 100% 97/97 100% 77/77 89% 82/92 Peer Specialist will meet with resident’s within 48 hours of admission and complete progress note to document meeting. 100% 64/64 100% 49/49 100% 64/64 100% 51/51 Each resident has documented contact with a peer supporter during (target is 100%). 100% 64/64 100% 49/49 100% 64/64 100% 51/51 Treatment Planning V10) 95% of patients have a preliminary treatment and transition plan developed within 3 working days of admission; Indicators 1Q2016 2Q2016 3Q2016 4Q2016 Service Integration Meeting and form completed by the end of the 3rd day. 100% 45/45 100% 45/45 100% 45/45 100% 45/45 Patient participation in Service Integration Meeting. 93% 42/45 95% 43/45 97% 44/45 95% 43/45 Social Worker participation in Service Integration Meeting. 100% 45/45 100% 45/45 100% 45/45 100% 45/45 Initial Comprehensive Psychosocial Assessments completed within 7 days of admission. 97% 44/45 95% 43/45 95% 43/45 93% 42/45 Initial Comprehensive Assessment contains summary narrative with conclusion and recommendations for discharge and Social 100% 45/45 100% 45/45 100% 45/45 100% 45/45
FY 2015 Manual Holds Mechanical Restraints Locked Seclusion Total Events Per Quarter Quarter 1 99 10 105 214 Quarter 2 107 16 97 220 Quarter 3 61 1 62 124 Quarter 4 94 4 92 190 Total # of events 361 31 356 748 *Average # of events per in FY 2015: 62 FY 2016 Manual Mechanical Restraints Locked Seclusion Total Events Per Quarter Quarter 1 95 6 75 176 Quarter 2 61 0 43 104 Quarter 3 108 0 72 180 Quarter 4 99 3 59 161 Total # of events 363 9 249 621 *Average # of events per month in FY 2016 to date: 52 Action Plan: will receive initial and ongoing education training in MOAB, Non-Violent Communication, and Motivational Interviewing to assist in establishing therapeutic relationships so that when a crisis begins staff will be more influential and effective in preventing the use of seclusions and restraints. 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 have maintained continuing education credits and have received the ten hours of annual required by ¶216; DATE HRS PRESENTER 4Q2015 17 April – June 2015 1Q2016 4 July – September 2015 2Q2016 19 October – December 2015 3Q2016 14 January – 2016
4/7/2016 1 Beyond PTSD: Complex Trauma Caused by Childhood Interpersonal Abuse Jessica Lloyd, Psychology Intern 4/14/2016 1 Mentalization Based Treatment Daniel Price, MD 4/20/2016 1 Medical Staff QA & PI Committee William Nelson, MD 4/21/2016 1.5 Equine Assisted Therapy - The Model Hilary Spear, Rec Therapist Heidi Blodgett, Rec Therapist 4/28/2016 1 Treating the Not Guilty by Reason of Insanity Patient: Legal, Ethical and Clinical Issues Alex de Nesnera, MD 5/12/2016 1 A case history and introduction to Punjabi Culture Steven Macchione, Psychology Intern 5/17/2016 1 Medical QA/PI Committee William Nelson, MD 5/19/2016 1 A Complex Case Discussion Noel Ngai, PsyD; Tatiana Gregor, EdD; Regana Sisson, MD; Maureen Martin, OT 5/26/2016 1 Fire-Setting: Who, Why and How Brooke Hoffman, PsyD 6/2/2016 1 Hope in the Clinical Context: How Practicing Clinicians Define and Use Hope in Sessions Brooke Hoffman, PsyD 6/9/2016 1 Precision Medicine: Clinical Applications of Pharmacogenomics Perry, PharmD 6/16/2016 1.5 Dartmouth Review: Cultural Aspects of Psychotic Disorder Regana Sisson, MD 6/17/2016 6 Evaluating the Validity of Miranda Waivers and the Trustworthiness of Confessions Alen Goldstein, PhD, ABPP 6/23/2016 1 A Multi-Disciplinary Case Presentation Graham Danzer, Psychology Intern 6/30/2016 1 Psychosis, Seizures or Both? George MD V25) Riverview certifies that staffing ratios required by ¶202 are met, and makes available documentation that shows actual staffing for up to one recent month; Staff Type Consent Decree Ratio General Medicine Physicians 1:75 Psychiatrists 1:25 Psychologists 1:25 Nursing 1:20 Social Workers 1:15 Mental Health Workers 1:6 Recreational/Occupational Therapists/Aides 1:8 With 92 beds, Riverview regularly or exceeds the staffing ratio requirements of the consent decree.
with the report of the first review due on or before July 1, 2016. The scope of the review and the selection of the independent consultant to require the approval of the Court Master. choice of consultant are under review at this time. I recommend that the mental health workers who are most familiar with the patients be invited by the charge nurse on the unit to attend at least the initial portion of the treatment team meetings for those patients in order to provide input and observations, and that acuity specialists be invited to attend whenever it is deemed appropriate by the charge nurse. Current and relevant portions of the treatment plans, such as interventions, shall be maintained on the unit and reviewed with the charge nurse by the mental health workers assigned to those patients. Changes are in process to determine how to best use the knowledge of the mental health workers in the treatment team meetings. This is reviewed and implemented on each unit in the hospital. Processes for ensuring that the most current treatment information is being made available to all staff on an ongoing basis. I recommend that unit activity logs be maintained on each unit and that the logs be reviewed at least on a monthly basis to determine whether any limitation in a patient’s access to treatment, services or outdoor areas has occurred. Unit activity logs are maintained on each unit. Nurse educators are training staff on the required documentation regarding any limitations to treatment, services or outdoor activities. Inpatient Psychiatric Services (ORYX Data Elements) The Joint Commission Quality Initiatives In 1987, The Joint Commission announced its Agenda for Change, which outlined a series of major steps designed to modernize the accreditation process. A key component of the Agenda for Change was the eventual introduction of standardized core performance measures into the accreditation process. As the vision to integrate performance measurement into accreditation became more focused, the name ORYX® was chosen for the entire initiative. The ORYX initiative became operational in March of 1999, when performance measurement systems began transmitting data to The Joint Commission on behalf of accredited hospitals and long term care
Motivational Services Dr. William Nelson 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 exceeded standards. Pine Tree Legal Assistance Dr. William Nelson Acting Clinical Director No services were provided during this timeframe. Project Staffing Cindy Michaud Business Services Manager All indicators met or 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 All indicators met standards. Waste Management Debora Proctor Executive Housekeeper 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 1Q2016 2Q2016 3Q2016 4Q2016 Total National Patent Safety Goal 1: Improve the accuracy of Patient Identification. Capital Community Dental Clinic assures accurate patient identification by: asking the July 100% 3/3 Aug N/A 0/0 Oct 100% 2/2 Nov 100% 1/1 Jan 100% 5/5 Feb 100% 3/3 Apr N/A May N/A 100% 15/15
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 1Q2016 2Q2016 3Q2016 4Q2016 Identification Data N/A N/A 100% 65/65 100% 51/51 Medical History, including chief complaint; HPI; past, social & family hx.; ROS, and physical exam w/in 24 hr. conclusion and plan N/A N/A 100% 65/65 100% 51/51 Summary of patient’s psychosocial as appropriate to the patients * N/A N/A 88% 57/65 61% 31/51 Psychiatric Evaluation in patient’s record w/in 24 hr of N/A N/A 99% 64/65 100% 51/51
admission Physician (TO/VO w/in 72 hr.) N/A N/A 96% 230/240 92% 23/25 Evidence of appropriate informed consent N/A N/A 100% 65/65 13 Refused 100% 51/51 14 Refused Clinical observations including the results of therapy. N/A N/A 100% 65/65 100% 51/51 Nursing discharge Progress Note with time of discharge departure N/A N/A 92% 60/65 90% 46/51 Consultation reports, when applicable N/A N/A 100% 52/52 81% 26/32 Results of autopsy, when performed N/A N/A N/A N/A Advance Directive Status on admission and SW follow up after N/A N/A 99% 64/65 88% 28/32 Notice of Privacy N/A N/A 94% 61/65 91% 29/32 Completion w/in 30 days of discharge date/discharge summary N/A N/A 100% 65/65 94% 30/32
Baseline Average Baseline Range Q32016 Average Q32016 April Average April Range May Average May Range June Average June Range Orders 12.1 0-31 11 1-37 13 1-37 14 2-37 13.8 2-37 Scheduled 4.9 0-17 7 0-21 6 1-20 7 1-20 6.7 0-21 PRNs 5.9 0-19 10 0-21 7 0-21 8 1-21 7.6 1-21 Medication Number Range Average Number of Patients (Baseline) 3Q2016 Average April May June 4Q2016 Average < 5 7 5 4 4 5 4 5 – 9 30 18 24 20 18 21 10 – 14 38 32 32 32 28 31 15 – 19 15 15 11 16 20 16 20 – 24 4 9 8 9 8 8 25 – 29 2 3 5 4 4 4 > 30 2 1 3 3 3 3 Number of Patients Falling into Range of Medication Orders Nursing Responsible Party: Renee Pfingst, RN, Acting Director of Nursing I. Measure Name: Mandate Occurrences Definition: When no volunteers are to cover a required staffing need, an employee is mandated to cover the staffing need according to policy. This creates difficulty for the employee who is required to unexpectedly stay at work up to 16 hours. It also creates a safety risk. Objective: Through collaboration among direct care staff and management, solutions will be identified to improve the staffing process in order to reduce and eventually eliminate mandate
Responsible Party: Julia Duncan, Peer Support Coordinator Indicator: Inpatient Consumer Survey Return Rate Definition: 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. 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 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 based on unit baseline with the end target being 50%. Survey Return Rate Unit Baseline Target 1Q2016 2Q2016 3Q2016 4Q2016 YTD The inpatient consumer survey is the primary tool for collecting LK 15% 50% 44% 7/16 23% 3/13 64% 7/11 9% 1/11 35% 18/51 LS 5% 50% 0% 0/21 54% 7/13 13% 2/16 0% 0/10 15% 9/60
data on how patients feel about the services they are provided at the hospital. UK 45% 50% 18% 3/17 25% 4/16 19% 5/26 13% 3/22 18% 15/81 US 30% 50% 88% 7/8 100% 7/7 0% 0/5 12% 1/8 53% 15/28 Overall 27% 17/62 43% 21/49 24% 14/58 10% 5/51 25% 57/220 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: # Indicators 1Q 2016 2Q 2016 3Q 2016 4Q 2016 YTD Average 1 I am better able to deal with crisis. 69% 82% 53% 70% 69% 2 My symptoms are not bothering me as much. 79% 77% 64% 65% 71% 3 The medications I am taking help me control symptoms that used to bother me. 75% 70% 42% 65% 63% 4 I do better in social situations. 71% 64% 56% 70% 65% 5 I deal more effectively with daily problems. 73% 83% 64% 64% 71% 6 I was treated with dignity and respect. 71% 65% 56% 65% 64% 7 Staff here believed that I could grow, change and recover. 69% 62% 56% 70% 64% 8 I felt comfortable asking questions about my treatment and medications. 68% 68% 72% 70% 70% 9 I was encouraged to use self-help/support groups. 72% 75% 58% 70% 69% 10 I was given information about how to manage my medication side effects. 68% 53% 64% 70% 64% 11 My other medical conditions were treated. 65% 69% 64% 55% 63% 12 I felt this hospital stay was necessary. 65% 48% 58% 40% 53% # Indicators 1Q 2016 2Q 2016 3Q 2016 4Q 2016 YTD Average
1. Safety Concern (Trash dumpster lock and chain broken) 4/12/16 0541 Parking Lot in rear of building Maintenance immediately repaired the chain and lock. While doing rounds, security found the dumpster unlocked. The potential for patients to get into the dumpster was very high. This would expose them to numerous items of contraband and would be a huge safety and security issue. NOD notified.