Action Plan: Auditing Nurse Supervisor provides education to staff during auditing process. Nursing administration will continue to follow up and audit all falls. Pain Assessment Carolyn Dimek, RN, MS Pain Re-Assessment Audit Form I. Measure Name: Pain Reassessment Audit - Patient Recovery Measure Description: Untreated pain impairs an individual’s ability to carry out their activities of daily living diminishing his or her quality of life; it can cause anxiety, fear, anger, or depression. Nursing acknowledges the impact of untreated pain on patient recovery and for this reason the objective of Nursing’s Pain PI is to ensure patients are being assessed for pain and re-assessed if required. All MARs are reviewed for the month for pain reported and corresponding reassessment; the information is located on form #838 ‘Pain Flow Sheet.’ The information is documented on the “Pain Assessment and Re-assessment Audit Form” for monthly and quarterly calculation. Audits were initiated in January 2013, January and February 2013 comprise the baseline data of 38%. Type of Measure: Performance Improvement Results Target Data elements Baseline Jan/Feb 2013 1Q 2017 2Q 2017 3Q 2017 4Q 2017 YTD 90% Compliance Number of audits performed 89 116 87 118 41 362 Number of patients with pain reported on Form 838 29 65 51 53 17 186 Number of reassessments completed 11 47 40 52 16 155 Number of reassessments reported within clinically appropriate timeframe (1-2 hours after oral medication and within 1 hour of intramuscular 11 47 40 52 16 155
11. On Form # 407RN 2 Hour Seclusion and Restraint Breaks 2 hour breaks are completed at appropriate intervals and signed by RN? N/A N/A 100% 100% N/A 100% Target Data Elements Baseline 4Q2016 1Q 2017 2Q 2017 3Q 2017 4Q 2017 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 N/A 75% 100% N/A 88% 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 N/A 100% 100% N/A 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 N/A 75% 0% N/A 36% 15. Were debriefings DB1 & DB2 completed at appropriate times? 99% 89% 96% 99% 100% 96% 16. Is patient debriefing in the chart? 89% 93% 94% 99% 100% 97% 19. Was Form 470 TX Focused Treatment Plan Review completed within 24 hours? 88% 91% 92% 95% 93% 93% Overall Compliance 93% 92% 94% 89% 96% 93% Data Analysis: Baseline data compiled August 2015, with updates to Seclusion and Restraint procedure, forms, and audit tool occurring since that time. The 1Q2017 showed a compliance rate of 92%, a 1% decrease from 4Q2016 and a 4% increase from baseline. Four elements increased and 4 elements decreased with negligible statistical impact. The 2Q2017 shows an overall compliance of 94%, a 2% increase from 1Q2017 and 6% above baseline. Seven elements increased while none decreased. The 3Q2017 shows an 89% overall compliance, a 5% decrease from 2Q2017 and 3% above baseline. Four elements increased, three
Data Analysis: The Pharmacy Department monitors patients’ renal function, electrolyte levels, and metabolic parameters to identify areas for medication use optimization, and polyantipsychotic therapy. Action Plan: DDPC’s continuing effort to strive for excellence in patient care involves enhancing current monitoring and reporting. Comments: The pharmacy team in collaboration with other departments looks forward to the expansion and enhancement of the clinical programs. II. Measure Name: Medication Management Monitoring Measure Description: The Psychiatric Emergency Order Type of Measure: Performance Improvement Process Element No Yes 1Q 2017 2Q 2017 3Q 2017 4Q 2017 YTD Reason for Target Pharmacy received PE orders 0 3 100% 100% 100% 100% 100% Actual 100% 100% 100% 100% 100% Target Did RPh need to resolve PE orders 3 0 0% 0% 0% 0% 0% Actual 50% 10% 13% 100% 82% Target Were PE meds Clearly identified when clarified 0 3 100% 100% 100% 100% 100% Actual 100% 100% 88% 100% 97% Target Was any PE written for up to 72 hours, stopped by writing “Discontinue Emergency Meds”? 3 0 100% 100% 100% 100% 100% Actual 100% 100% 88% 100% 97% Target Was a one-time PE intervention specified as an Emergency Med? 3 0 100% 100% 100% 100% 100% Actual 100% 100% 100% 100% 100% Target Did any Emergency Med not end in 72 hours? 3 0 0 0 0 0 0 Some were continued, but had appropriate orders. Actual 0 0 0 0 0 Target Was PE co-signed by psychiatrist if ordered by a PA? 100% 100% 100% 100% 100% Actual N/A N/A N/A N/A N/A Data Analysis: There were three orders pertaining to psychiatric emergencies during the 4Q2017. Action Plan: Continued monitoring and data collection during psychiatric emergencies has resulted in favorable results for the 4Q2017.