Medical History, including chief complaint; HPI; past, social & family hx., ROS, and physical exam w/in 24 hrs., conclusion and plan. 100% 32/32 100% 25/25 100% 25/25 100% 82/82 Summary of patient’s psychosocial needs as appropriate to the patients * 94% 30/32 92% 23/25 92% 23/25 93% 76/82 Psychiatric Evaluation in patient’s record w/in 24 hrs. of admission 100% 32/32 100% 25/25 100% 25/25 100% 82/82 Psychiatric Evaluation authenticated within 60 hours of admission 84% 27/32 92% 23/25 96% 24/25 90% 74/82 Physician (TO/VO w/in 72 hrs.) 91% 162/179 88% 142/161 88% 135/154 89% 439/494 Evidence of appropriate informed consent 93% 26/28 4 declined 100% 25/25 96% 24/25 96% 75/78 4 declined Clinical observations including the results of therapy. 100% 32/32 100% 25/25 100% 25/25 100% 82/82 Nursing discharge Progress Note with time of discharge departure 100% 32/32 96% 24/25 100% 25/25 98% 81/82 Consultation reports, when applicable 100% 10/10 22=N/A 100% 9/9 16=N/A 100% 10/10 15=N/A 100% 29/29 53=N/A Advance Directive Status on admission and SW follow up after 94% 30/32 96% 25/25 100% 25/25 98% 80/82 Indicator and Rationale for Selection 1Q2017 2Q2017 3Q2017 4Q2017 YTD Notice of Privacy 100% 32/32 100% 25/25 100% 25/25 100% 82/82 Chart Completion w/in 30 days of discharge date/discharge summary completed within 30 days 97% 31/32 100% 25/25 100% 25/25 99% 81/82 Discharge Packet sent to follow up provider within 5 days of discharge. 100% 32/32 84% 21/25 80% 20/25 89% 73/82
Is order complete? N/A 72% 100% On order, is the intervention stated in behavioral terms? 92% 56% 97% 100% 84% Target 100% Does the time of the orders match interventions and times on Nursing forms? N/A 100% 93% 100% 98% Is Medical Staff Seclusion and Restraint Progress Note complete (both sides)? 100% 44% 100% Is the time of the 1 hour face to face within an hour of the event? 100% 100% 94% 100% 98% If PA, did PA consult with attending? 92% 100% 83% 100% 94% Are the details of the event similar on all forms? 100% 100% 100% Did the medical provider participate in the Seclusion and Restraint treatment plan review? N/A 100% 92% 94% 95% Overall Compliance 96% 84% 95% 99% 93% Data Analysis: There were 12 seclusion events in the 1Q2017 with an overall compliance of 84%. 2Q2017 shows an increase in seclusion events to 27, with a significant increase in overall compliance to 95%; 11% above 1st Quarter. 3Q2017 shows a decrease to 9 seclusions events with an overall compliance of 99%: 4% above 2Q2017 and 15% above 1Q2017. Medical Staff has met the goal for three data elements of measurement by meeting the 100% goal for 4 consecutive months. Questions “Is order complete” “Is Medical Staff Seclusion and Restraint Progress Note complete (both sides)?” and “Are the details of the event similar on all forms?” will be removed from aggregation and will be evaluated by spot check in 6 months to evaluate and ensure consistent and reliable documentation compliance. Goal: 100% Compliance with Medical Staff Documentation Action Plan: The plan moving forward is to continue to monitor compliance with the above data elements and to discuss and address non-compliance with the Medical Staff. III. Measure Name: All elements of a medication order are complete.