Northeast Cardiology Associates (NECA) Dr. Michelle Gardner Clinical Director All indicators met standards. Norris, Inc. Mark Faulkner Director of Facilities 1 indicator did not meet standards: Compliance, as Quarterly Sprinkler System testing was not performed during this quarter as contracted. All other indicators met standards. Otis Elevator Mark Faulkner Director of Facilities All indicators met standards. Penobscot Community Health Care (PCHC) Dr. Michelle Gardner Clinical Director Indicator met standards. Project Staffing Carol Davis Business Manager All indicators exceeded standards. Securitas Mark Faulkner Director of Facilities All indicators met or exceeded standards. The Healing Staff Dr. Michelle Gardner Clinical Director Contract not utilized during timeframe. UniFirst Mark Faulkner Director of Facilities All indicators met standards. Vista Staffing Dr. Michelle Gardner Clinical Director Contract not utilized during timeframe. WBRC Architects Engineers Mark Faulkner Director of Facilities All indicators exceeded standards. Worldwide Travel Staffing Carolyn Dimek Director of Nursing Two indicators received a score of 1-2; 1 being didn’t meet standard, 2 being met standards: 1) Maintain a Safe & Therapeutic Environment for Patients and 2) Oversee Agency staff assigned to unit for compliance and competency related to safe and therapeutic patient care. Medication Management Medication Errors and Adverse Reactions TJC PI.01.01.01 EP14: The hospital collects data on the following: Significant medication errors. (See also LD.04.04.01, EP 2; MM.08.01.01, EP 1) TJC PI.01.01.01 EP15: The hospital collects data on the following: Significant adverse drug reactions. (See also LD.04.04.01, EP 2; MM.08.01.01, EP 1)
Dietary Bobbie Lindsey I. Measure Name: ServSafe Training Measure Description: ServSafe is a food and beverage safety training and certificate program administered by the National Restaurant Association Type of Measure: Quality Assurance Results Target Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD 1Q2017 93% 100% 100% 100% 100% 100% Actual 93% 93% 93% Data Analysis: The data indicates that we fell short of our goal of 100% certification by 7%. Action Plan: Continue to offer the ServSafe class yearly, or as needed, to ensure that all staff remain certified. I would like to include other staff members in the hospital that handle food for patients. Comments: A ServSafe class will be held this fiscal year for employees whose certificates are scheduled to expire and untrained newer employees. Facilities Mark Faulkner I. Measure Name: Life Safety Standard Compliance for Above Ceiling Work Measure Description: Analyze compliance to Policy FP-9 involving Above Ceiling Work to verify conformance to life safety standards involving maintaining fire and smoke ratings of the space above the ceilings throughout the Hospital. Type of Measure: Performance Improvement Results Target Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD
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% 57/57 Summary of patient’s psychosocial needs as appropriate to the patients * 94% 30/32 92% 23/25 93% 53/57 Psychiatric Evaluation in patient’s record w/in 24 hrs. of admission 100% 32/32 100% 25/25 100% 57/57 Psychiatric Evaluation authenticated within 60 hours of admission 84% 27/32 92% 23/25 88% 50/57 Physician (TO/VO w/in 72 hrs.) 91% 162/179 88% 142/161 89% 304/340 Evidence of appropriate informed consent 93% 26/28 4 Declined 100% 25/25 96% 51/53 4 Declined Clinical observations including the results of therapy. 100% 32/32 100% 25/25 100% 57/57 Nursing discharge Progress Note with time of discharge departure 100% 32/32 96% 24/25 98% 56/57 Consultation reports, when applicable 100% 10/10 22 N/A 100% 9/9 16 N/A 100% 19/19 38 N/A Advance Directive Status on admission and SW follow up after 94% 30/32 96% 24/25 95% 54/57 Notice of Privacy 100% 32/32 100% 25/25 100% 57/57 Chart Completion w/in 30 days of discharge date/discharge summary completed within 30 days 97% 31/32 100% 25/25 98% 56/57 Discharge Packet sent to follow up provider within 5 days of discharge. 100% 32/32 84% 21/25 93% 53/57
safety and provide therapeutic care for patients. Type of Measure: Performance Improvement Results Target Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD FY2016 Average 100% 100% 100% 100% 100% Vacancy Rate % 15% 14% 13% 14% # Vacancies Posted 14 8 8 8 # Vacancies Filled Within 45 Days 6 3 3 3 % Posted & Filled Within 45 Days 40% 38% 38% 38% Data Analysis: This is new data collection in an effort to reduce extended time periods of vacant positions Action Plan: Increase percentage rate of filled quarterly posted vacancies within 45 days of posting.
FY 2014-2017 Hospital Acquired Infections Type of Infection 1Q 2015 1Q 2016 1Q 2017 2Q 2015 2Q 2016 2Q 2017 3Q 2015 3Q 2016 3Q 2017 4Q 2015 4Q 2016 4Q 2017 UTI 0 0 0 0 0 0 0 0 0 0 URI 0 0 0 0 0 0 0 0 0 0 LRI 0 0 1 0 0 0 0 0 0 0 Skin 0 0 0 0 0 0 0 1 0 0 Totals 0 0 0 0 0 0 0 1 0 0 Infection Rate 0 0 0.26 0 0 0 0 0.28 0 0 Infection Rate per 1000 patient days: Total number of infections per unit x 1000 = % Total number of inpatient days 1st Quarter 2015 = 3256 1st Quarter 2016 = 3361 1st Quarter 2017=3889 2nd Quarter 2015 = 3550 2nd Quarter 2016 = 3508 2nd Quarter 2017=3987 3rd Quarter 2015 = 3453 3rd Quarter 2016 = 3587 3rd Quarter 2017= 4th Quarter 2015 = 3422 4th Quarter 2016 =3584 4th Quarter 2017= II. 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 hands D2: I received information on how to cover my cough or sneeze to prevent the spread of illness Type of Measure: Performance Improvement Results Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD Target: D1 90% Quarterly response rate “agree/strongly agree” for D1 & D2 is set at 90% 2012: D1 response rate: 80% 86% 45% 66% Target: D2 90% 2012: D2 response 86% 45% 66%
Orders do times match for interventions initiated and time of events? 9. Are details of event similar on all forms without discrepancies #408, #409, and Order sheets? 100% 100% 100% 100% 10. Is Form # 470 Nursing Assessment Protocol for Seclusion and Restraint completed? 88% 100% 100% 100% 11. On Form # 407RN 2 Hour Seclusion and Restraint Breaks 2 hour breaks are completed at appropriate intervals and signed by RN? 84% 100% 97% 99% Results Target Data Elements 4Q2016 1Q 2017 2Q 2017 3Q 2017 4Q 2017 YTD 100% Compliance 12. On Form #407RN 2 Hour Seclusion and Restraint Breaks is time ended for S/R completed and signed by RN 59% 89% 86% 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? 94% 72% 96% 84%
Target Polyantipsychotic Therapy TBD TBD TBD TBD TBD TBD Actual 33.6% 21% 27.3% Data Analysis: While justification has been a requirement for polyantipsychotic therapy (PAPT) it was completed on a case-by-case basis. It was decided to do so in a more formalized manner. This data represents the first step in developing that formalized process. Beginning in July, it was decided that data would be collected in a centralized manner and presented to the Pharmacy & Therapeutics to create a baseline data set of PAPT. For the quarter, 21% of patients at DDPC were receiving treatment with more than one antipsychotic, while 63% of the patients were receiving therapy during the quarter. Action Plan: DDPC will continue to develop the formalized PAPT tracking and reporting the findings to the Medical Director and prescribers at the facility. A formal, centralized process for PAPT will enable the facility to better optimize the patients’ therapies and identify trends and areas for improvement, all while striving for excellence in patient care. XI. Measure Name: Metabolic Monitoring Measure Description: Metabolic syndrome is a well-known side effect of second generation antipsychotics (SGAs) and represents a common comorbidity in the psychiatric population. The majority of patients prescribed antipsychotics are prescribed an entity from the SGA sub-class. The purpose of this is to ensure that DDPC is monitoring the patients it serves appropriately and to the best of its ability, while mitigating the consequences of metabolic syndrome as much as possible. Type of Measure: Performance Improvement Results Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD Target Complete/ Up-to-date Metabolic Parameters TBD 50% 65% 70% 75% 75% Actual 69.9% 85.7% 77.8%
patient contact. Actual 48% 37% 43% B. Measure Name: Direct Patient Contact - Therapeutic Recreation Results Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD Target Percent of time spent in direct patient contact. 53% March 2015 50% 50% 50% 50% 50% Actual 55% 56% 56% C. Measure Name: Direct Patient Contact - Clinical Services Results Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD Target Percent of time spent in direct patient contact. 35% March 2015 50% 50% 50% 50% 50% Actual 41% 39% 40% D. Measure Name: Direct Patient Contact- Ancillary Services (Dietician, Chaplain, Peer Support) Results Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD Target Percent of time spent in direct patient contact. 31% March 2015 50% 50% 50% 50% 50% Actual 55% 49% 52%