Results Unit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD Target: 0 HAI # of HAI per quarter FY2012 0 HAI 0 HAI 0 HAI Data Analysis: There were no hospital acquired infections for 1Q2018, and no hospital acquired infection for 4Q2017. Action Plan: Continue to Monitor H. A. Infections FY2016 FY2017 FY2018 1st Quarter H.A.I. Rate 0 1 0 2nd Quarter H.A.I. Rate 0 0 3rd Quarter H.A.I. Rate 1 0 4th Quarter H.A.I. Rate 0 0 Average H.A. Infection Rate 0.25 0.25 FY2016-2018 Hospital Acquired Infections Type of Infection 1Q 2016 1Q 2017 1Q 2018 2Q 2016 2Q 2017 2Q 2018 3Q 2016 3Q 2017 3Q 2018 4Q 2016 4Q 2017 4Q 2018 UTI 0 0 0 0 0 0 0 0 0 URI 0 0 0 0 0 0 0 0 0 LRI 0 1 0 0 0 0 0 0 0 Skin 0 0 0 0 0 1 0 0 0 Totals 0 0 0 0 0 1 0 0 0 Infection Rate 0 0.26 0 0 0 0.28 0 0 0 Measure Name: Patient & Family Education on Hand Hygiene/Cough Etiquette Measure Description: Prior to discharge, a questionnaire will be distributed to each patient that includes the following questions: D1: I received information on how to stay healthy by washing my D2: I received information on how to my cough or sneeze to prevent the spread of illness Type of Measure: Performance Improvement
5. On Form 408 Nursing Seclusion/Restraint Progress Note, Form 470 Nursing Assessment Protocol for Seclusion and Restraint, and Physician Orders do times match for interventions initiated and time of events? 97% 79% 79% 9. Are details of event similar on all forms without discrepancies 408, 409, and Order sheets? 97% 98% 98% 10. Is Form 470 Nursing Assessment Protocol for Seclusion and Restraint completed? 96% 11. On Form # 407RN 2 Hour Seclusion and Restraint Breaks 2 hour breaks are completed at appropriate intervals and signed by RN? N/A 100% 100% Target Data Elements Baseline 4Q2016 1Q 2018 2Q 2018 3Q 2018 4Q 2018 YTD 100% 12. On Form #407RN 2 Hour Seclusion and Restraint Breaks is time ended for S/R completed and signed by RN N/A 100% 100% 13. On Form #407 Seclusion & Restraint Monitoring and Assessment 15 minute checks are completed at appropriate intervals, with Pt’s behavior documented in behavioral terms as it pertains to release criteria, times, dated, and initialed by staff? N/A 100% 100% 14. On Form #407 Seclusion & Restraint Monitoring and Assessment did each staff member that initialed 15 minute checks complete last page of form with signature and title? N/A 100% 100% 15. Were debriefings DB1 & DB2 completed at appropriate times? 99% 100% 100% 16. Is patient debriefing in the chart? 89% 100% 100%
Patients who do not meet criteria for metabolic syndrome 10 Patients who cannot be classified at this time 13 VI. Measure Name: Veriform Medication Room Audits Measure Description: Quarterly Completion by Unit Audits Type of Measure: Quality Assurance Results Unit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD Target All FY2017 100% 100% 100% 100% 100% 100% Actual 100% 100% Methodology: Monthly, the Pharmacy Department performs comprehensive inspections of medication rooms, central supply areas, and the medical clinic. Over 44 criteria are monitored in the audits utilizing Veriform software. Data Analysis: The medication room audits have been concluded for 1Q2018 without completion deficiencies. Pharmacy continues to strive for audits that are 100% complete Action Plan: The Pharmacy Department will continue to send reminders early in the process to ensure that completion, compliance, verification and reporting is performed in a timely fashion. Comments: Continuous monitoring of the medication room audits and approval by the responsible individuals has provided satisfactory results for this quarter. VII. Measure Name: Medication Dispensing Process Measure Unit Baseline 4Q2016 Goal 1Q2018 2Q2018 3Q2018 4Q2018 Controlled Substance Loss Data: Pyxis-CII Safe Compare Report. All 0% Target: Actual: 0% 0% Monthly CII Safe Vendor Receipt Report. Rx 0 Target: Actual: 0 0 Monthly Pyxis Unresolved Controlled Drug Discrepancies. All 0/ month Target: Actual: 0 14 (4.66/mo)
Measures of drug reactions, adverse drug events and other management data. Rx 1.25 Target: Actual: 0 0 Resource Documentation Reports of Clinical Interventions. Rx 397 Target: Actual: 100% 32 Psychiatric Emergency Process: Monthly audit of all psych emergencies measures against 8 criteria. All 100% Target: Actual: 100% 100% Operational Audit: Monthly audit of 8 operational indicators from CPS contract. * Rx 100% Target: Actual: 100% 88% * a corrective action plan was provided and initiated immediately Risk Management Heather Racine RN, BSN I. Measure Name: Allegations of Abuse, Neglect, and Exploitation Measure Description: All patients have the right to be free from abuse, neglect or exploitation, as well as the fear of being abused, neglected or exploited. Allegations or information indicating that abuse, neglect, or exploitation may have occurred must be thoroughly and promptly investigated with appropriate follow-up action taken. Type of Measure: Performance Improvement Methodology: The numerator will be all allegations for the quarter that were found to be promptly investigated with appropriate follow-up action taken. The denominator will be all allegations for the quarter. Results Unit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD Target: 100% compliance with allegation process # of allegations per quarter 1Q2018 100% 14/14 100% 14/14 100% 14/14
Measure Name: 30 Day Readmissions Modified Root Cause Analyses Measure Description: Once the hospital has identified potentially preventable readmissions, it is expected to conduct an in-depth review of the discharge planning process for a sample of such readmission (at least 10% of potentially preventable readmissions, or 15 cases/quarter, whichever is larger is suggested but not required), in order to determine whether there was an appropriate discharge planning evaluation, discharge plan, and implementation of the discharge plan. Having identified factors that contribute to preventable readmissions, hospitals are expected to revise their discharge planning and related processes to address these factors. Type of Measure: Quality Assurance Results Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD Target FY2017 100% 100% 100% 100% 100% 100% Actual 100% 100% Data Analysis: There were two 30 day readmissions in 1Q2018. One readmission was due to a patient needing medical hospitalization and was transferred to a medical hospital. She was discharged to the hospital on 7/19/17 and admitted back to DDPC on 7/25/17. Per social work discharge planning procedure 5-1: If the patient is not readmitted in the allowed time (72 hours), then the discharge order becomes permanent and a Release Plan will be required. The second readmission was on 7/5/17 when a patient refused to continue medication compliance after release back to Penobscot County Jail on 6/9/17. The medication prescribed was on the jail formulary and the only interruption within this discharge was reported by the jail administrator that the administration and medical departments were not notified that this inmate was returning. An internal review was done regarding this situation. It was established that contact was made by the Forensic Liaison with Penobscot County Jail Transport Department. That Transport Department did not notify administration or medical departments that they were doing so. Nothing was found stating that there was clinical hand-off by the hospital to the jail. Medications were given to corrections staff, but not passed on directly to the medical department at the jail. Action Plan: A procedure for Forensic Discharge Planning will be developed to address forensic patients returning to jail. Educating the that the Forensic Liaison is there to help facilitate discharge planning needs with jail departments as needed.
within 5 more days if extension is requested? *Overall Compliance of Nursing Supervisor and Social Worker addressing grievance 80% 85% 85% Element 1: Unit Staff compliant with addressing grievance Element 2: Unit Staff completed form correctly and notified Nurse Supervisor Element 3: Nurse Supervisor addressed grievance within four hours Element 4: Nurse Supervisor completed form correctly and forwarded to Social Worker Element 5: Social Worker addressed grievance within five days or more than five days if extension is requested Element 6: Overall Compliance of Nursing Supervisor and Social Worker Addressing Grievance Data Analysis: All data elements decreased from 4Q2017 to 1Q2018. Overall compliance for Nursing Supervisor and Social Worker addressing grievance decreased from 98% to 85%. Action Plan: Working on finalization of new complaint and grievance form which are more clearly marked where documentation and signatures are needed. With revision of grievance policy will seek 24-hour response time instead of four hours by CNM or nurse supervisor to allow staff time to gather information and meet with patients during the day when they are not available during the day. Further training by patient advocates and management for unit staff would be beneficial as well. Continue to provide feedback to Director of Nursing and supervisors when forms are not completed correctly. Staff Education and Development Jenny Bamford-Perkins, MSN, RN Measure Name: Mandatory Staff Education Measure Description: Both direct and non-direct care employees of Dorothea Dix Psychiatric Center are required to complete monthly mandatory staff education. The Staff Education Department will conduct monthly audits using the education database. Type of Measure: Performance Improvement Methodology: The numerator will be the number of staff that completed their monthly education requirements for the quarter and the denominator will be the total number of staff for the quarter. The goal is to have 100% compliance of monthly education requirements by the staff education year end in 2Q of each fiscal year.
PWERST 82% 97% 100% REPORTING POLICIES 82% 99% 99% RN EXAM 100% S/R LP 84% 100% 74% TJCREP 84% 99% 100% Action Plan: Staff Education will complete monthly audits, send monthly e-mails to staff that have not completed their learning packets, send a notice to supervisors by the 3Q of the calendar year to address their staff that are out of compliance, and alert the superintendent of employees out of compliance. Measure Name: RN/MHW Additional Continuing Education Measure Description: Both Registered Nurses and Mental Health Workers are required to have additional continuing education specific to discipline. Methodology: The numerator will be the number of RN/MHW’s that completed additional continuing education requirements for the quarter and the denominator will be the total number of RN/MHW’s for the quarter. The goal is to have 100% compliance of additional continuing education requirements by the staff education year end in the 2Q of each fiscal year. Results Unit Baseline 1Q2018 3Q2017 4Q2017 1Q2018 2Q2018 Target % Compliance 100% 100% Actual % RNs completed 62% 62% % MHWs completed 66% 66% Data Analysis: This is a new measure starting 1Q2018. The above reflects Staff Education requirements for Nurses and Mental Health Workers for 1Q2018. The goal is for 100% compliance by the staff education year end in the 2Q of each fiscal year Action Plan: Staff Education has created multiple learning packets specific to each discipline which was released in September 2017. Staff Education will complete monthly audits, send monthly e-mails to staff that have not completed their learning packets, send a notice to supervisors by the 3Q of the calendar year to address their staff that are out of compliance, and alert the superintendent of employees out of compliance. Measure Name: Direct Care Staff Skills Fair Measure Description: All direct care staff members are required to attend Staff Education’s Skills Fair.
Methodology: The numerator will be the number of RN/MHW’s that attended the Direct Care Staff Skills Fair for the quarter and the denominator will be the total number of RN/MHW’s for the quarter. The goal is to have 100% compliance of Skills Fair attendance by the Staff Education year end in the 2Q of each fiscal year. Results Unit Baseline 3Q2017 4Q2017 1Q2018 2Q2018 Target % Attendance 1Q2018 71% 100% Actual 71% Data Analysis: This is a new measure, and the table above reflects staff education requirements for 1Q2018. The goal is for 100% compliance by the staff education year end in the 2Q of each fiscal year. Action Plan: Staff Education will offer monthly Skills Fairs to all direct care staff. Staff Education will send monthly e-mails to staff notifying them of the scheduled dates and times the Skills Fair will be offered. Staff Education will send a notice to supervisors by the 3Q of the calendar year to address their staff that are out of compliance, and alert the superintendent of employees out of compliance. Therapeutic Services Lisa J. Hall, OTR/L Measure Name: Provider Direct Patient Contact