· web view30 day readmissions % of discharges that returned within 30 days riverview apr may jun...
TRANSCRIPT
QUARTERLY REPORT ON ORGANIZATIONAL PERFORMANCE EXCELLENCE
THIRD STATE FISCAL QUARTER 2018January, February, March 2018
Rodney BouffardSuperintendent April 30, 2018
Table of Contents
Glossary of Terms, Acronyms, and Abbreviation....................................................................................iIntroduction....................................................................................................................................... ...iii
Consent Decree:Consent Decree Plan................................................................................................................1Patient Rights..........................................................................................................................1 Admissions..............................................................................................................................2 Peer Supports...........................................................................................................................8Treatment Planning..................................................................................................................9Medications............................................................................................................................12Discharges..............................................................................................................................13Staffing and Staff Training......................................................................................................16Use of Seclusion and Restraints..............................................................................................19Patient Elopements................................................................................................................34Patient Injuries.......................................................................................................................36Patient Abuse, Neglect, Exploitation, Injury or Death............................................................39Regulatory Compliance..........................................................................................................40
The Joint Commission:Hospital-Based Inpatient Psychiatric Services (HBIPS)............................................................41Contract Performance Indicators...........................................................................................42Adverse Reactions to Sedation or Anesthesia........................................................................44Healthcare Acquired Infections Monitoring & Management.................................................46Medication Errors and Adverse Drug Reactions.....................................................................47Inpatient Consumer Survey....................................................................................................5 1 Fall Reduction Strategies........................................................................................................58
Quality Assurance & Performance Improvement (QAPI):
Admissions.............................................................................................................................59Capital Community Clinic Dental Clinic...................................................................................67Dietetic Services.....................................................................................................................76Emergency Management.......................................................................................................82Harbor Treatment Mall..........................................................................................................87Health Information Technology (Medical Records)................................................................88Housekeeping.........................................................................................................................93Human Resources...................................................................................................................94Infection Control....................................................................................................................96Medical Staff..........................................................................................................................98Nursing.................................................................................................................................104Peer Support........................................................................................................................112Pharmacy Services................................................................................................................115Psychology............................................................................................................................120Rehabilitation Services.........................................................................................................123Risk Management.................................................................................................................124Safety & Security..................................................................................................................129Staff Education.....................................................................................................................133
Glossary of Terms, Acronyms & Abbreviations
ADC Automated Dispensing Cabinets (for medications)ADON Assistant Director of NursingAOC Administrator on CallCCM Continuation of Care Management (Social Work Services)CCP Continuation of Care PlanCH/CON Charges/ConvictedCMS Centers for Medicare & Medicaid ServicesCIVIL Voluntary, No Criminal Justice InvolvementCIVIL-INVOL Involuntary Civil Court Commitment (No Criminal Justice Involvement)CoP Community of Practice or
Conditions of Participation (CMS)CPI Continuous Process (or Performance) ImprovementCPR Cardio-Pulmonary ResuscitationCSP Comprehensive Service PlanDCC Involuntary District Court CommittedDCC-PTP Involuntary District Court Committed, Progressive Treatment PlanGAP Goal, Assessment, Plan DocumentationHOC Hand off CommunicationIMD Institute for Mental DiseaseICDCC Involuntary Civil District Court CommitmentICDCC-M Involuntary Civil District Court Commitment, Court Ordered MedicationsICDCC-PTP Involuntary Civil District Court Commitment, Progressive Treatment PlanIC-PTP+M Involuntary Commitment, Progressive Treatment Plan, Court Ordered MedicationsICRDCC Involuntary Criminal District Court CommitmentINVOL CRIM Involuntary Criminal CommitmentINVOL-CIV Involuntary Civil CommitmentISP Individualized Service PlanIST Incompetent to Stand TrialJAIL TRANS A patient who has been transferred to RPC from jail.JTF A patient who has been transferred to RPC from jail.LCSW Licensed Clinical Social WorkerLEGHOLD Legal HoldLPN Licensed Practical NurseMAR Medication Administration RecordMHW Mental Health WorkerMRDO Medication Resistant Disease Organism (MRSA, VRE, C-Dif)NASMHPD National Association of State Mental Health Program DirectorsNCR Not Criminally ResponsibleNOD Nurse on DutyNP Nurse PractitionerNPSG National Patient Safety Goals (established by The Joint Commission)
i
NRI NASMHPD Research Institute, Inc.OPS Outpatient Services Program (formally the ACT Team)OT Occupational TherapistPA or PA-C Physician’s Assistant (Certified)PCHDCC Pending Court HearingPCHDCC+M Pending Court Hearing for Court Ordered MedicationsPPR Periodic Performance Review – a self-assessment based upon TJC standards that are
conducted annually by each department head.PSD Program Services DirectorPTP Progressive Treatment PlanPRET Pretrial EvaluationR.A.C.E. Rescue/Alarm/Confine/ExtinguishRN Registered NurseRPC Riverview Psychiatric CenterRT Recreation TherapistSA Substance AbuseSAMHSA Substance Abuse and Mental Health Services Administration (Federal)SAMHS Substance Abuse and Mental Health Services, Office of (Maine DHHS)SBAR Acronym for a model of concise communications first developed by the US Navy
Submarine Command. S = Situation, B = Background, A = Assessment, R = Recommendation
SD Standard Deviation – a measure of data variability.Staff Development.
Seclusion, Locked
Patient is placed in a secured room with the door locked.
Seclusion, Open
Patient is placed in a room and instructed not to leave the room.
SRC Single Room Care (seclusion)STAGE III 60 Day Forensic EvaluationTJC The Joint Commission (formerly JCAHO, Joint Commission on Accreditation of
Healthcare Organizations)URI Upper Respiratory InfectionUTI Urinary Tract InfectionVOL Voluntary – SelfVOL-OTHER Voluntary – Others (Guardian)
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Introduction
The Riverview Psychiatric Center Quarterly Report on Organizational Performance Excellence has been created to highlight the efforts of the hospital and its staff members to provide evidence of a commitment to patient recovery, safety in culture and practices, and fiscal accountability. The report is structured to reflect a philosophy and contemporary practices in addressing overall organizational performance in a systems improvement approach instead of a purely compliance approach. The structure of the report also reflects a focus on meaningful measures of organizational process improvement while maintaining measures of compliance that are mandated through regulatory and legal standards.
The methods of reporting are driven by a nationally accepted focused approach that seeks out areas for improvement that were clearly identified as performance priorities. The American Society for Quality, National Quality Forum, Baldrige National Quality Program and the National Patient Safety Foundation all recommend a systems-based approach where organizational improvement activities are focused on strategic priorities rather than compliance standards.
There are three major sections that make up this report:
The first section reflects compliance factors related to the Consent Decree and includes those performance measures described in the Order Adopting Compliance Standards dated October 29, 2007. Comparison data is not always available for the last month in the quarter and is included in the next report.
The second section describes the hospital’s performance with regard to Joint Commission performance measures that are derived from the Hospital-Based Inpatient Psychiatric Services (HBIPS) and priority focus areas that are referenced in The Joint Commission standards:
I. Data Collection (PI.01.01.01)II. Data Analysis (PI.02.01.01, PI.02.01.03)III. Performance Improvement (PI.03.01.01)
The third section encompasses those departmental quality assurance and process improvement (QAPI) projects that are designed to improve the overall effectiveness and efficiency of the hospital’s operations and contribute to the system’s overall strategic performance excellence. Several departments and work areas have made significant progress in developing the concepts of this new methodology.
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CONSENT DECREEConsent Decree Plan
V1) The Consent Decree Plan, established pursuant to paragraphs 36, 37, 38, and 39 of the Settlement Agreement in Bates v. DHHS defines the role of Riverview Psychiatric Center in providing consumer-centered inpatient psychiatric care to Maine citizens with serious mental illness that meets constitutional, statutory, and regulatory standards.
The following elements outline the hospital’s processes for ensuring substantial compliance with the provisions of the Settlement Agreement as stipulated in an Order Adopting Compliance Standards dated October 29, 2007.
Patient Rights
V2) Riverview produces documentation that patients are routinely informed of their rights upon admission in accordance with ¶ 150 of the Settlement Agreement;
Indicators 1Q2018 2Q2018 3Q2018 4Q2018 YTD
1. Patients are routinely informed of their rights upon admission.
95%57/60
95%57/60
100%56/60
94%170/180
Patients are informed of their rights and asked to sign that information has been provided to them. If they refuse, staff documents the refusal and signs, dates & times the refusal.
3Q2018: Four patients lacked capacity.
V3) Grievance tracking data shows that the hospital responds to 90% of Level II grievances within five working days of the date of receipt or within a five-day extension.
Indicators 1Q2018 2Q2018 3Q2018 4Q2018 YTD
1. Level II grievances responded to by RPC on time.
0%0/11
0%0/1
100%1/1
8%1/13
2. Level I grievances responded to by RPC on time.
90%98/109
97%56/58
100%64/64
94%218/231
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CONSENT DECREEAdmissions
V4) Quarterly performance data shows that in four consecutive quarters, 95% of admissions to Riverview meet legal criteria:
ADMISSIONS 1Q20182Q201
8 3Q2018 4Q2018TOTA
LCIVIL: 37 35 36 108VOL 1 0 1 2INVOL (EIC) 9 6 5 20DCC 22 28 26 76DCC-PTP 5 1 4 10FORENSIC: 20 26 26 7260 DAY EVAL 13 10 13 39JAIL TRANSFER 0 4 5 9IST 3 6 4 13NCR 4 6 4 14TOTAL 57 61 62 180
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CONSENT DECREEV5) Quarterly performance data shows that in two out of four consecutive quarters, the % of
readmissions within 30 days of discharge does not exceed one standard deviation from the national mean as reported by NASMHPD
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
5.00
10.00
15.00
20.00
25.00
30.00
35.00
30 Day Readmissions
% o
f disc
harg
es th
at re
turn
ed
with
in 3
0 da
ys
This graph depicts the percent of discharges from the facility that returned within 30 days of a discharge of the same patient from the same facility. For example; a rate of 10.0 means that 10% of all discharges were readmitted within 30 days.
The graphs shown on the next page depict the percent of discharges from the facility that returned within 30 days of a discharge of the same patient from the same facility stratified by forensic or civil classifications. For example; a rate of 10.0 means that 10% of all discharges were readmitted within 30 days.
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CONSENT DECREE
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
5.00
10.00
15.00
20.00
25.00
30 Day ReadmissionsForensic Patients
% o
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harg
es th
at re
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with
in 3
0 da
ys
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
5.00
10.00
15.00
20.00
25.00
30.00
35.00
40.00
30 Day ReadmissionsCivil Patients
% o
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es th
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CONSENT DECREEV6) Riverview documents, as part of the Performance Improvement & Quality Assurance process,
that the Director of Social Work reviews all readmissions occurring within 60 days of the last discharge; and for each patient who spent fewer than 30 days in the community, evaluated the circumstances to determine whether the readmission indicated a need for resources or a change in treatment and discharge planning or a need for different resources and, where such a need or change was indicated, that corrective action was taken;
Review of Re-Admissions Occurring Within 60 Days:
Indicators 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Director of Social Services reviews all readmissions occurring within 60 days of the last discharge, and for each patient who spent fewer than 30 days in the community, evaluated the circumstances of the readmission to determine an indicated need for resources or a change in treatment and discharge planning or the need for alternative resources; and, where such a need or change was indicated, that corrective action was taken.
100%9/9
100%7/7
100%4/4
100%20/20
3Q2018: Nine patients were re-admitted in the 3Q2018 within sixty days of discharge. Of the nine re-admitted four spent less than 30 days in the community. One patient from UK spent 22 days in the community at his group home and returned due to mental health relapse related to medications. Two patients from UK spent 15 and 26 days respectively in the community on PTP orders before returning to the hospital on Green Papers for PTP order non-compliance. One NCR patient on US returned from Maine General Medical Center on a medical leave for an acute medical issue.
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CONSENT DECREEReduction of Re-Hospitalization for Outpatient Services Programs (OPS) Patients
Indicators 1Q2018 2Q2018 3Q2018 4Q2018 YTD
1. The Program Service Director of the Outpatient Services Program will review all patient cases of re-hospitalization from the community for patterns and trends of the contributing factors leading to re-hospitalization each quarter. The following elements are considered during the review:
a. Length of stay in communityb. Type of residence (group home, apartment, etc.) c. Geographic location of residenced. Community support networke. Patient demographics (age, gender, financial)f. Behavior pattern/mental statusg. Medication adherenceh. Level of communication with Outpatient
Treatment
100%4/4
100%6/6
100%3/3
100%13/13
2. Outpatient Services will work closely with inpatient treatment team to create and apply discharge plan incorporating additional supports determined by review noted in #1.
100% 100% 100% 100%
3Q2018: Three patients returned to RPC during the quarter: one from an independent apartment returned to RPC due to admitting to illicit drug use, in violation of court order; one from an independent apartment returned to RPC due to admission to Maine Medical Center where patient was admitted due to cardiac arrest resulting from Heroin use, in violation of court order; and one from a group home where the patient threatened staff and displayed increased psychiatric symptoms.
We had three patients successfully discharge, one to community group home, one to community independent apartment, and one to a community supervised apartment. We also had one patient transfer to DDPC Outpatient Services (OPS), and one patient was discharged from OPS after passing away in hospice due to a medical condition.
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CONSENT DECREEV7) Riverview certifies that no more than 5% of patients admitted in any year have a primary
diagnosis of mental retardation, traumatic brain injury, dementia, substance abuse or dependence.
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CONSENT DECREEPATIENT ADMISSION DIAGNOSIS 1Q2018 2Q2018 3Q2018 4Q2018 YTDANXIETY DISORDER, UNSPECIFIED 2 2ATTENTION DEFICIT HYPERACTIVITY DISORDER, UNSPCIFIED TYPE 1 1BIPOLAR DISORD, CRNT EPISODE MANIC SEVER, W PSYCH FEATURES 4 1 2 7
BIPOLAR DISORD, CRNT EPISODE MANIC W/O PSYCH FEATURES, UNSPECIFIED
1 1
BIPOLAR DISORD, CRNT EPISODE DEPRESS, SEVERE W/PSYCH FEATURES
1 1
BIPOLAR DISORDER, CURRENT EPISODE HYPOMANIC 2 2BIPOLAR DISORDER, CURRENT EPISODE MIXED, UNSPECIFIED 1 1 2BIPOLAR DISORDER, UNSPECIFIED 9 3 4 16BIPOLAR II DISORDER 1 1CATATONIC SCHIZOPHRENIA 1 1DELIRIUM DUE TO KNOWN PHYSIOLOGICAL CONDITION 1 1DELUSIONAL DISORDERS 1 1GENERALIZED ANXIETY DISORDER 1 1 2MAJOR DEPRESSV DISORD, SINGLE EPSD, SEVERE W/PSYCH FEATURES
3 3
MAJOR DEPRESSV DISORD, SINGLE EPSD, SEVERE W/O PSYCH FEATURES
1 1 2
MAJOR DEPRESSV DISORD, SINGLE EPSD, UNSPEC 1 1 2MAJOR DEPRESSV DISORD,RECURRENT, UNSPEC 1 1MAJOR DEPRESSV DISORDER, RECURRENT, SEVERE W/PSYCH 1 1MAJOR DEPRESSV DISORDER, RECURRENT, SEVERE W/O PSYCH FEATURES
1 1
MILD COGNITIVE IMPAIRMENT, SO STATED 1 1MOOD DISORDER DUE TO KNOWN PHYSIOL COND W/MIXED FEATURES 1 1OTH PSYCH DISORDER NOT DUE TO A SUB OR KNOWN PHYSIOL COND 1 1
OTHER SCHIZOAFFECTIVE DISORDERS 1 1OTHER SPECIFIC PERSONALITY DISORDER 1 1PARANOID SCHIZOPHRENIA 3 1 1 5PERSONALITY DISORDER, UNSPECIFIED 1 1POSTTRAUMATIC STRESS DISORDER-UNSPEC 3 3 4 10SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE 13 16 29SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TYPE 6 3 9SCHIZOAFFECTIVE DISORDER, UNSPECIFIED 5 11 5 21SCHIZOPHRENIA, UNSPECIFIED 9 9 10 28UNSPECIFIED MOOD DISORDER (AFFECTIVE) 3 3 6UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOL COND
7 6 5 18
Total Admissions 57 61 62 180
Peer Supports
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CONSENT DECREEQuarterly performance data shows that in three out of four consecutive quarters:
V8) 100% of all patients have documented contact with a peer specialist during hospitalization;
V9) 80% of all treatment meetings involve a peer specialist.
Indicators 1Q2018 2Q2018 3Q2018 4Q2018 YTD
1. Attendance at Comprehensive Treatment Team meetings. (v9)
80%271/339
87%277/320
84%330/393
83%878/1052
2. Attendance at Service Integration meetings. (v8)
74%42/57
76%46/60
81%51/62
78%139/179
3. Contact during admission. (v8) 100%57/57
100%60/60
100%62/62
100%179/179
4. Community Integration/Bridging Inpatient & OPS. Inpatient trips OPS
100%
4084
100%
38181
100%
25223
100%
103488
5. 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.
66%33/50
58%34/59
63%40/64
62%107/173
6. Grievances responded to on time by Peer Support, within 1 day of receipt.
96%105/109
90%53/58
100%43/43
96%201/210
7. Peer Specialist will meet with residents within 48 hours of admission and complete progress note to document meeting.
88%50/57
100%60/60
100%62/62
96%172/179
8. Each resident has documented contact with a peer supporter during their hospitalization (target is 100%).
100%57/57
100%60/60
100%62/62
100%179/179
Treatment Planning
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CONSENT DECREEV10) 95% of patients have a preliminary treatment and transition plan developed within three
working days of admission;
Indicators 1Q2018 2Q2018 3Q2018 4Q2018 YTD
1. Service Integration Meeting and form completed by the end of the 3rd day.
98%44/45
100%45/45
97%44/45
99%133/135
2. Patient participation in Service Integration Meeting.
96%43/45
95%43/45
93%42/45
95%128/135
3. Social Worker participation in Service Integration Meeting.
100%45/45
100%45/45
97%44/45
99%134/135
4. Initial Comprehensive Psychosocial Assessments completed within seven days of admission.
93%42/45
95%43/45
93%42/45
94%127/135
5. Initial Comprehensive Assessment contains summary narrative with conclusion and recommendations for discharge and Social Worker role.
100%45/45
100%45/45
100%45/45
100%135/135
6. Annual Psychosocial Assessment completed and current in chart.
100%45/45
100%10/10
100%10/10
100%65/65
3Q2018: 1. One Service Integration Form was late due to a direct admit to UK.2. Three patients declined to meet for the Service Integration Meeting and declined on follow up.4. Three Comprehensive Psychosocial Assessments were not completed within the seven-day timeframe. All of them have since been completed and are in the charts; supervision follow up was completed with the individual social workers.
V11) 95% of patients also have individualized treatment plans in their records within seven days thereafter;
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CONSENT DECREE
Indicators 1Q2018 2Q2018 3Q2018 4Q2018 YTD
1. Progress notes in GAP/Incidental/Contact format will indicate at minimum weekly 1:1 meeting with all patients on assigned CCM caseload.
96%43/45
100%45/45
100%45/45
99%133/135
2. Treatment plans will have measurable goals and interventions listing patient strengths and areas of need related to transition to the community or transition back to a correctional facility.
100%45/45
100%45/45
100%45/45
100%135/135
V12) Riverview certifies that all treatment modalities required by ¶155 are available.
The treatment modalities listed below as listed in ¶155 are offered to all patients according to the individual patient’s ability to participate in a safe and productive manner, as determined by the treatment team and established in collaboration with the patient during the formulation of the individualized treatment plan.
Treatment Modality
Provision of Services Normally by….
Medical StaffPsychology Nursing
SocialServices
Rehabilitation Services/
Treatment MallGroup and Individual Psychotherapy XPsychopharmacological Therapy XSocial Services XPhysical Therapy XOccupational Therapy XADL Skills Training X XRecreational Therapy XVocational/Educational Programs XFamily Support Services and Education X X XSubstance Abuse Services XSexual/Physical Abuse Counseling XIntroduction to Basic Principles of Health, Hygiene, and Nutrition X X
An evaluation of treatment planning and implementation, performed in accordance with Attachment D, demonstrates that, for 90% of the cases reviewed:
V13) The treatment plans reflect:
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CONSENT DECREE
Screening of the patient’s needs in all the domains listed in ¶61; Consideration of the patient’s need for the services listed in ¶155; Treatment goals for each area of need identified, unless the patient chooses not, or is not yet
ready, to address that treatment goal; Appropriate interventions to address treatment goals; Provision of services listed in ¶155 for which the patient has an assessed need; Treatment goals necessary to meet discharge criteria; and Assessments of whether the patient is clinically safe for discharge;
V14) The treatment provided is consistent with the individual treatment plans;
V15) If the record reflects limitations on a patient’s rights listed in ¶159, those limitations were imposed consistent with the Rights of Recipients of Mental Health Services.
An abstraction of pertinent elements of a random selection of charts is periodically conducted to determine compliance with the compliance standards of the consent decree outlined in parts V13, V14, and V15.
This review of randomly selected charts revealed substantial compliance with the consent decree elements. Individual charts can be reviewed by authorized individuals to validate this chart review.
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CONSENT DECREEMedications
V16) Riverview certifies that the pharmacy computer database system for monitoring the use of psychoactive medications is in place and in use, and that the system as used meets the objectives of ¶168.
Riverview utilizes a Pyxis Medstation 4000 System for the dispensing of medications on each patient care unit. A total of six devices, one on each of the four main units and in each of the two special care units, provide access to all medications used for patient care, the pharmacy medication record, and allow review of dispensing and administration of pharmaceuticals.
A database program, HCS Medics, contains records of medication use for each patient and allows access by an after-hours remote pharmacy service to these records, to the Pyxis Medstation 4000 System. The purpose of this after-hours service is to maintain 24-hour coverage and pharmacy validation and verification services for prescribers.
Records of transactions are evaluated by the Director of Pharmacy and the Clinical Director to validate the appropriate utilization of all medication classes dispensed by the hospital. The Pharmacy and Therapeutics Committee, a multidisciplinary group of physicians, pharmacists, and other clinical staff, evaluate issues related to the prescribing, dispensing, and administration of all pharmaceuticals.
The system as described can provide information to process reviewers on the status of medications management in the hospital and to ensure the appropriate use of psychoactive and other medications.
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CONSENT DECREEDischarges
Quarterly performance data shows that in three consecutive quarters:
V17) 86% of patients who remained ready for discharge were transitioned out of the hospital within seven days of a determination that they had received maximum benefit from inpatient care;
V18) 93% of patients who remained ready for discharge were transitioned out of the hospital within 30 days of a determination that they had received maximum benefit from inpatient care;
V19) 100% of patients who remained ready for discharge were transitioned out of the hospital within 45 days of a determination that they had received maximum benefit from inpatient care (with certain patients excepted, by agreement of the parties and Court Master).
Barriers to Discharge Following Clinical Readiness:Housing (8) Five patients discharged within 30 days post clinical readiness Three patients discharged after 45 days post clinical readiness Four of the above patients were waiting on Group Home, one for a Supported Apartment, one NF/Assisted Living, one Waiver 21 home bed, and one Section 8 Apartment.
The previous four quarters are displayed in the table below:
Target >>Within 7 days Within 30 days Within 45 days 45+ days
70% 80% 90% < 10%2Q2018 N=39 82% 92% 95% 5%1Q2018 N=44 86% 93% 100% 0%4Q2017 N=36 78% 92% 97% 3%3Q2017 N=49 78% 88% 92% 8%
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Cumulative percentages & targets are as follows:
Within 7 days = (36) 82% (target 70%)
Within 30 days = (5) 93% (target 80%)
Within 45 days = (0) 93% (target 90%)
Post 45 days = (3) 7% (target 0%)
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CONSENT DECREEAn evaluation of treatment and discharge planning, performed in accordance with Attachment D, demonstrates that, for 90% of the cases reviewed:
V20) Treatment and discharge plans reflect interventions appropriate to address discharge and transition goals;
V20a) For patients who have been found not criminally responsible or not guilty by reason of insanity, appropriate interventions include timely reviews of progress toward the maximum levels allowed by court order; and the record reflects timely reviews of progress toward the maximum levels allowed by court order;
V21) Interventions to address discharge and transition planning goals are in fact being implemented;
V21a) For patients who have been found not criminally responsible or not guilty by reason of insanity, this means that, if the treatment team determines that the patient is ready for an increase in levels beyond those allowed by the current court order, Riverview is taking reasonable steps to support a court petition for an increase in levels.
Indicators 1Q2018 2Q2018 3Q2018 4Q2018 YTD
1. The Patient Discharge Plan Report will be reviewed and updated by each Social Worker minimally one time per week.
100%11/11
100%12/12
100%11/11
100%34/34
2. The Patient Discharge Plan Report will be reviewed/updated minimally one time per week by the Director of Social Services.
100%11/11
100%12/12
100%11/11
100%34/34
3. The Patient Discharge Plan Report will be sent out weekly as indicated in the approved court plan.
100%11/11
100%12/12
100%11/11
100%34/34
4. Each week the Social Work team and Director will meet and discuss current housing options provided by the respective regions and prioritize referrals.
100%11/11
100%12/12
100%11/11
100%34/34
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CONSENT DECREEV22) The Department demonstrates that 95% of the annual reports for forensic patients are
submitted to the Commissioner and forwarded to the court on time.
Indicators 1Q2018 2Q2018 3Q2018 4Q2018 YTD
1. Institutional Reports will be completed, reviewed internally, and delivered to the court within 10 business days of request.
100%3/3
100%6/6
100%5/5
100%14/14
2. The assigned CCM will review the new court order with the patient and document the meeting in a progress note or treatment team note.
100%7/7
100%3/3
100%3/3
100%13/13
3. Annual Reports (due in December) to the Commissioner for all inpatient NCR patients are submitted annually
N/A N/A N/A N/A
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CONSENT DECREEStaffing and Staff Training
V23) Riverview performance data shows that 95% of direct care staff have received 90% of their annual training.
Indicators 1Q2018 2Q2018 3Q2018 4Q2018 YTD1. Riverview and Contract staff will attend CPR training bi-annually.
100% 88% 90% 91%28/28 30/34 50/55 108/119
2. Riverview and Contract staff will complete annual mandatory training.
74% 39% 44% 51%472/637 300/778 370/842 1142/2257
3. Riverview and contract staff will attend BRO training bi-annually.
46% 67% 67% 60%193/416 260/389 296/443 749/1248
3Q2018:1. Corrective action has been taken; all non-compliant staff will be brought into compliance within two weeks.2. Employees and supervisors have been informed. Corrective action is being taken.3. Behavior Response Options (BRO) trainings continue to be offered at least monthly. Majority of staff trained provide direct care to patients.
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CONSENT DECREEV24) Riverview certifies that 95% of professional staff have maintained professionally-required
continuing education credits and have received the 10 hours of annual cross-training required by ¶216;
DATE HRS TITLE PRESENTER3Q2017 5 January-March 20174Q2017 6 April-June 20171Q2018 3 July-September 20172Q2018 8 October-December 20171/11/18 1 Kelly Staples from DHHS Peer Support in Maine1/25/18 1 Deborah Rosch Eifert, PhD Issues & Practices in Treatment of
Transgender Individuals -- Part I2/1/18 1 Deborah Rosch Eifert, PhD Issues & Practices in Treatment of
Transgender Individuals -- Part II2/15/18 1 George Costin, MD Psychiatry & the nature of reality3/1/18 1 George Costin, MD Synchronicity & its importance for
Psychiatrists3/15/18 1 Sarah Gaffney, CBIS Maine Brain Injury Resources &
Supports
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CONSENT DECREEV25) 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 RatioGeneral Medicine Physicians 1:75Psychiatrists 1:25Psychologists 1:25Nursing 1:20Social Workers 1:15Mental Health Workers 1:6Recreational/Occupational Therapists/Aides 1:8
With 92 beds, Riverview regularly meets or exceeds the staffing ratio requirements of the consent decree.
Staffing levels are most often determined by an analysis of unit acuity, individual monitoring needs of the patients who reside on specific units, and unit census.
V26) The evaluation of treatment and discharge planning, performed in accordance with Attachment D, demonstrates that staffing was sufficient to provide patients access to activities necessary to achieve the patients’ treatment goals, and to enable patients to exercise daily and to recreate outdoors consistent with their treatment plans.
Treatment teams regularly monitor the needs of individual patients and make recommendations for ongoing treatment modalities. Staffing levels are carefully monitored to ensure that all treatment goals, exercise needs, and outdoor activities are achievable. Staffing does not present a barrier to the fulfillment of patient needs. Staffing deficiencies that may periodically be present are rectified through utilization of overtime or mandated staff members.
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CONSENT DECREEUse of Seclusion and Restraints
V27) Quarterly performance data shows that, in three out of four quarters, total seclusion and restraint hours do not exceed one standard deviation from the national mean as reported by NASMHPD;
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun4Q2017 1Q2018 2Q2018 3Q2018 4Q2018
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00
Percent of Patients Secluded
% o
f pati
ents
se
clude
d at
leas
t onc
e
This graph depicts the percent of unique patients who were secluded at least once. For example, rates of 3.0 means that 3% of the unique patients served were secluded at least once.
The following graphs depict the percent of unique patients who were secluded at least once stratified by forensic or civil classifications. For example; rates of 3.0 means that 3% of the unique patients served were secluded at least once. The hospital-wide results from Dorothea Dix are compared to the civil population results at Riverview due to the homogeneous nature of these two sample groups.
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CONSENT DECREE
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
2.00
4.00
6.00
8.00
10.00
12.00
Percent of Patients SecludedForensic Patients
% o
f pati
ents
se
clude
d at
leas
t onc
e
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
2.00
4.00
6.00
8.00
10.00
12.00
Percent of Patients SecludedCivil Patients
% o
f pati
ents
se
clude
d at
leas
t onc
e
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CONSENT DECREE
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
5.00
Seclusion Hours
# of
hou
rs p
atien
ts sp
ent i
n se
clusio
n fo
r eve
ry 1
000
inpa
tient
hou
rs
This graph depicts the number of hours’ patients spent in seclusion for every 1000 inpatient hours. For example, a rate of 0.8 means that one hour was spent in seclusion for each 1250 inpatient hours.
The following graphs depict the number of hours’ patients spent in seclusion for every 1000 inpatient hours stratified by forensic or civil classifications. For example, a rate of 0.8 means that hour was spent in seclusion for each 1250 inpatient hours. The hospital-wide results from Dorothea Dix are compared to the civil population results at Riverview due to the homogeneous nature of these two sample groups.
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CONSENT DECREE
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
0.50
1.00
1.50
2.00
2.50
Seclusion HoursForensic Patients
# of
hou
rs p
atien
ts sp
ent i
n se
clusio
n fo
r eve
ry 1
000
inpa
tient
hou
rs
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00
Seclusion HoursCivil Patients
# of
hou
rs p
atien
ts sp
ent i
n se
clusio
n fo
r eve
ry 1
000
inpa
tient
hou
rs
23
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CONSENT DECREE
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
18.00
Percent of Patients Restrained
% o
f pati
ents
who
wer
e re
stra
ined
at l
east
onc
e
This graph depicts the percent of unique patients who were restrained at least once and includes all forms of restraint of any duration. For example; a rate of 4.0 means that 4% of the unique patients served were restrained at least once.
The following graphs depict the percent of unique patients who were restrained at least once stratified by forensic or civil classifications, and includes all forms of restraint of any duration. For example; a rate of 4.0 means that 4% of the unique patients served were restrained at least once. The hospital-wide results from Dorothea Dix are compared to the civil population results at Riverview due to the homogeneous nature of these two sample groups.
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CONSENT DECREE
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
Percent of Patients RestrainedForensic Patients
% o
f pati
ents
who
wer
e re
stra
ined
at l
east
onc
e
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
Percent of Patients RestrainedCivil Patients
% o
f pati
ents
who
wer
e re
stra
ined
at l
east
onc
e
25
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CONSENT DECREE
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
0.50
1.00
1.50
2.00
2.50
Restraint Hours
# of
hou
rs p
atien
ts sp
ent i
n re
stra
int
for e
very
100
0 in
patie
nt h
ours
This graph depicts the number of hours’ patients spent in restraint for every 1000 inpatient hours - includes all forms of restraint of any duration. For example; a rate of 1.6 means those two hours were spent in restraint for each 1250 inpatient hours.
The following graphs depict the number of hours’ patients spent in restraint for every 1000 inpatient hours stratified by forensic or civil classifications - includes all forms of restraint of any duration. For example; a rate of 1.6 means those two hours were spent in restraint for each 1250 inpatient hours. The hospital-wide results from Dorothea Dix are compared to the civil population results at Riverview due to the homogeneous nature of these two sample groups.
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CONSENT DECREE
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
0.20
0.40
0.60
0.80
1.00
1.20
Restraint HoursForensic Patients
# of
hou
rs p
atien
ts sp
ent i
n re
stra
int
for e
very
100
0 in
patie
nt h
ours
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CONSENT DECREE
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
0.20
0.40
0.60
0.80
1.00
1.20
Restraint HoursCivil Patients
# of
hou
rs p
atien
ts sp
ent i
n re
stra
int
for e
very
100
0 in
patie
nt h
ours
Confinement Event Detail3Q2018
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CONSENT DECREE
21% (16/78) of the average hospital population experienced some form of confinement event during 3Q2018. Four of these patients (5% of the average hospital population) accounted for 54% of the confinement events.
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CONSENT DECREE
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CONSENT DECREEV28) Riverview demonstrates that, based on a review of three quarters of data, for 95% of seclusion
events, seclusion was employed only when absolutely necessary to protect the patient from causing physical harm to self or others or for the management of violent behavior.
V29) Riverview demonstrates that, based on a review of three quarters of data, for 95% of restraint events involving mechanical restraints, the restraint was used only when absolutely necessary to protect the patient from serious physical injury to self or others.
V30) Riverview demonstrates that, based on a review of three quarters of data, for 95% of seclusion and restraint events, the hospital achieved an acceptable rating for meeting the requirements of paragraphs 182 and 184 of the Settlement Agreement, in accordance with a methodology defined in Attachments E-1 and E-2.
See Pages 35-38
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CONSENT DECREEConfinement Events Management
3Q2018 Seclusion Events (32) Events
Standard Threshold Compliance1. The record reflects that seclusion was absolutely necessary to
protect the patient from causing physical harm to self or others, or if the patient was examined by a physician or physician extender prior to implementation of seclusion, to prevent further serious disruption that significantly interferes with other patients’ treatments.
95% 100%
2. The record reflects that lesser restrictive alternatives were inappropriate or ineffective. This can be reflected anywhere in record.
90% 100%
3. The record reflects that the decision to place the patient in seclusion was made by a physician or physician extender.
90% 100%
4. The decision to place the patient in seclusion was entered in the patient’s records as a medical order.
90% 100%
5. The record reflects that, if the physician or physician extender was not immediately available to examine the patient, the patient was placed in seclusion following an examination by a nurse.
90% 100%
6. The record reflects that the physician or physician extender personally evaluated the patient within 30 minutes after the patient has been placed in seclusion, and if there is a delay, the reasons for the delay.
90% 100%
7. The record reflects that the patient was monitored every 15 minutes. (Compliance will be deemed if the patient was monitored at least three times per hour.)
90% 100%
8. Individuals implementing seclusion have been trained in techniques and alternatives.
90% 100%
9. The record reflects that reasonable efforts were taken to notify guardian or designated representative as soon as possible that patient was placed in seclusion.
75% 100%
10. The medical order states time of entry of order and that number of hours in seclusion shall not exceed 4.
85% 100%
11. The medical order states the conditions under which the patient may be sooner released.
85% 100%
12. The record reflects that the need for seclusion is re-evaluated at least every two hours by a nurse.
90% 100%
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CONSENT DECREE13. 14. The record reflects that the two-hour re-evaluation was conducted
while the patient was out of seclusion room unless clinically contraindicated.
70% 100%
15. 16. The record includes a special check sheet that has been filled out to document reason for seclusion, description of behavior and the lesser restrictive alternatives considered.
85% 100%
17. 18. The record reflects that the patient was released, unless clinically contraindicated, at least every two hours or as necessary for eating, drinking, bathing, toileting or special medical orders.
85% 100%
19. 20. Reports of seclusion events were forwarded to Clinical Director and Patient Advocate.
90% 100%
21. 22. The record reflects that, for persons with mental retardation, the regulations governing seclusion of patients with mental retardation were met.
85% 100%
23. 24. The medical order for seclusion was not entered as a PRN order. 90% 100%
25. 26. Where there was a PRN order, there is evidence that physician was counseled.
95% N/A
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CONSENT DECREEConfinement Events Management
3Q2018 Mechanical Restraint Events (0) Events
Standard Threshold Compliance1. The record reflects that restraint was absolutely necessary to
protect the patient from causing serious physical injury to self or others.
95% N/A
2. The record reflects that lesser restrictive alternatives were inappropriate or ineffective.
90% N/A
3. The record reflects that the decision to place the patient in restraint was made by a physician or physician extender
90% N/A
4. The decision to place the patient in restraint was entered in the patient’s records as a medical order.
90% N/A
5. The record reflects that if a physician or physician extended was not immediately available to examine the patient, the patient was placed in restraint following an examination by a nurse.
90% N/A
6. The record reflects that the physician or physician extender personally evaluated the patient within 30 minutes after the patient has been placed in restraint, or, if there was a delay, the reasons for the delay.
90% N/A
7. The record reflects that the patient was kept under constant observation during restraint.
95% N/A
8. Individuals implementing restraint have been trained in techniques and alternatives.
90% N/A
9. The record reflects that reasonable efforts taken to notify guardian or designated representative as soon as possible that patient was placed in restraint.
75% N/A
10. The medical order states time of entry of order and that number of hours shall not exceed four.
90% N/A
11. The medical order shall state the conditions under which the patient may be sooner released.
85% N/A
12. The record reflects that the need for restraint was re-evaluated every two hours by a nurse.
90% N/A
13. The record reflects that re-evaluation was conducted while the patient was free of restraints unless clinically contraindicated.
70% N/A
14. The record includes a special check sheet that has been filled out to document the reason for the restraint, description of behavior and the lesser restrictive alternatives considered.
85% N/A
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CONSENT DECREE15.16. The record reflects that the patient was released as
necessary for eating, drinking, bathing, toileting or special medical orders.
90% N/A
17.18. The record reflects that the patient’s extremities were released sequentially, with one released at least every fifteen minutes.
90% N/A
19.20. Copies of events were forwarded to Clinical Director and Patient Advocate.
90% N/A
21.22. For persons with mental retardation, the applicable regulations were met.
85% N/A
23.24. The record reflects that the order was not entered as a PRN order.
90% N/A
25.26. Where there was a PRN order, there is evidence that physician was counseled.
95% N/A
27.28. A restraint event that exceeds 24 hours will be reviewed against the following requirement: If total consecutive hours in restraint, with renewals, exceeded 24 hours, the record reflects that the patient was medically assessed and treated for any injuries; that the order extending restraint beyond 24 hours was entered by Clinical Director (or if the Clinical Director is out of the hospital, by the individual acting in the Clinical Director’s stead) following examination of the patient; and that the patient’s guardian or representative has been notified.
90% N/A
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CONSENT DECREEPatient Elopements
V31) Quarterly performance data shows that, in one out of four quarters, the number of patient elopements does not exceed one standard deviation from the national mean as reported by NASMHPD.
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
Elopement Rate
# of
elo
pmen
ts th
at o
ccur
red
for e
very
100
0 in
patie
nt d
ays
This graph depicts the number of elopements that occurred for every 1000 inpatient days. For example, a rate of 0.25 means that one elopement occurred for each 4000 inpatient days. An elopement is defined as any time a patient is “absent from a location defined by the patient’s privilege status regardless of the patient’s leave or legal status.”
The following graphs depict the number of elopements stratified by forensic or civil classifications that occurred for every 1000 inpatient days. For example, a rate of 0.25 means that one elopement occurred for each 4000 inpatient days. The hospital-wide results from Dorothea Dix are compared to the civil population results at Riverview due to the homogeneous nature of these two sample groups.
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CONSENT DECREE
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
Elopement RateForensic Patients
# of
elo
pmen
ts th
at o
ccur
red
for e
very
100
0 in
patie
nt d
ays
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
0.20
0.40
0.60
0.80
1.00
1.20
Elopement RateCivil Patients
# of
elo
pmen
ts th
at o
ccur
red
for e
very
100
0 in
patie
nt d
ays
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CONSENT DECREEPatient Injuries
V32) Quarterly performance data shows that, in four out of four quarters, the number of patient injuries does not exceed one standard deviation from the national mean as reported by NASMHPD.
The NASMHPD standards for measuring patient injuries differentiate between injuries that are considered reportable to the Joint Commission as a performance measure and those injuries that are of a less severe nature. While all injuries are currently reported internally, only certain types of injuries are documented and reported to NRI for inclusion in the performance measure analysis process.
“Non-reportable” injuries include those that require: 1) No Treatment, or 2) Minor First Aid
Reportable injuries include those that require: 3) Medical Intervention, 4) Hospitalization or where, 5) Death Occurred.
The comparative statistics graph only includes those events that are considered “Reportable” by NASMHPD.
Type and Cause of Injury by Month
Type - Cause January February March 3Q2018Accident 2 1 3Assault (Patient to Patient) 2 2FallInjury – Other 3 1 1 5Self-Injurious Behavior 2 3 11 16Total 7 6 13 26
Severity of Injury by Month
Severity January February March 3Q2018No Treatment 5 2 1 8Minor First Aid 2 4 9 15Medical Intervention Required 3 3Hospitalization RequiredDeath OccurredTotal 7 6 13 26
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CONSENT DECREE
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2.00
Patient Injury Rate
# of
pati
ent i
njur
ies t
hat o
ccur
red
for e
very
100
0 in
patie
nt d
ays
This graph depicts the number of patient injury events that occurred for every 1000 inpatient days. For example, a rate of 0.5 means that one injury occurred for each 2000 inpatient days.
The following graphs depict the number of patient injury events stratified by forensic or civil classifications that occurred for every 1000 inpatient days. For example, a rate of 0.5 means that one injury occurred for each 2000 inpatient days. The hospital-wide results from Dorothea Dix are compared to the civil population results at Riverview due to the homogeneous nature of these two sample groups.
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CONSENT DECREE
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2.00
Patient Injury RateForensic Patients
# of
pati
ent i
njur
ies t
hat o
ccur
red
for e
very
100
0 in
patie
nt d
ays
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2.00
Patient Injury RateCivil Patients
# of
pati
ent i
njur
ies t
hat o
ccur
red
for e
very
100
0 in
patie
nt d
ays
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CONSENT DECREEPatient Abuse, Neglect, Exploitation, Injury or Death
V33) Riverview certifies that it is reporting and responding to instances of patient abuse, neglect, exploitation, injury or death consistent with the requirements of ¶ 192-201 of the Settlement Agreement.
Type of Allegation 1Q2018 2Q2018 3Q2018 4Q2018 YTDAbuse Verbal 2 4 6 12Abuse Physical 2 4 7 13Abuse Sexual 3 3 2 8Neglect 1 1 0 2Coercion/Exploitation 6 4 2 12Total 14 16 17 47
Riverview utilizes several vehicles to communicate concerns or allegations related to abuse, neglect, or exploitation:
1. Staff members complete an incident report upon becoming aware of an incident or an allegation of any form of abuse, neglect, or exploitation.
2. Patients have the option to complete a grievance or communicate allegations of abuse, neglect, or exploitation during any interaction with staff at all levels, Peer Support personnel, or the Patient Advocate(s).
3. Any allegation of abuse, neglect, or exploitation is reported both internally and externally to appropriate stakeholders, including:
Superintendent and/or AOC Adult Protective Services Guardian Patient Advocate
4. Allegations are reported to the Risk Manager through the incident reporting system and fact-finding or investigations occur at multiple levels. The purpose of this investigation is to evaluate the event to determine if the allegations can be substantiated or not and to refer the incident to the patient’s treatment team, hospital administration, or outside entities.
5. When appropriate to the allegation and circumstances, investigations involving law enforcement, family members, or human resources may be conducted.
6. The Human Rights Committee, a group consisting of consumers, family members, providers, and interested community members, and the Medical Executive Committee receive a report on the incident of alleged abuse, neglect, and exploitation monthly.
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CONSENT DECREERegulatory Compliance
V34) Riverview maintains Joint Commission accreditation;
Riverview successfully completed an accreditation survey with The Joint Commission in October 2016. The Hospital and the Outpatient Services (OPS) are both fully accredited until October 2019.
V35) Riverview maintains its hospital license;
Riverview maintains its licensing status as required through the Maine Department of Health and Human Services Division of Licensing and Regulatory Services. The hospital is currently licensed through October 31, 2018. Outpatient Services (OPS) is licensed until November 2, 2018.
V36) The hospital seeks CMS certification;
The hospital submitted an application for CMS certification in October 2017. The hospital is providing additional information required by CMS for certification.
V37) Riverview conducts quarterly monitoring of performance indicators in key areas of hospital administration, in accordance with the Consent Decree Plan, the accreditation standards of The Joint Commission, and according to a QAPI plan reviewed and approved by the Advisory Board each biennium, and demonstrates through quarterly reports that management uses that data to improve institutional performance, prioritize resources and evaluate strategic operations.
Riverview complies with this element of substantial compliance as evidenced by the current Integrated Plan for Performance Excellence, the data and reports presented in this document, the work of the Integrated Performance Excellence Committee, and sub-groups of this committee that are engaged in a transition to an improvement orientated methodology that is supported by The Joint Commission and is consistent with modern principles of process management and strategic methods of promoting organizational performance excellence. The Advisory Board approved the Integrated Plan for Performance Excellence in June 2017.
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JOINT COMMISSIONHospital-Based Inpatient Psychiatric Services (HBIPS)
The Inpatient Psychiatric Facility Quality Reporting System (IPFQRS) measures are required by the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (Riverview’s accrediting agency). These measures were created due to a request made to The Joint Commission in 2003 to identify and implement a set of core performance measures for hospital-based inpatient psychiatric services. The measures have changed over the years.
IPFQRS Measures
April
201
7
May
201
7
June
201
7
July
201
7
Augu
st 2
017
Sept
embe
r 20
17
Oct
ober
201
7
Nov
embe
r 201
7
Dece
mbe
r 201
7
Janu
ary
2018
Febr
uary
201
8
Mar
ch 2
018
HBIPS-1: Percent of inpatients screened within the first three days of admission for risk of violence to self or others, substance use, psychological trauma history, and patient strengths.TJC target: 95%
100% 83% 91% 89% 94% 85% 100% 92% 100% 95% 95% 100%
HBIPS-2: Number of hours patients spent in physical restraint for every 1000 inpatient hours.TJC target: < 0.47
0.03 0.01 0.01 0.02 0.03 0.02 0.01 0.04 0.07 0.03 0.02 0.02
HBIPS-3:Number of hours patients spent in seclusion for every 1000 inpatient hours.TJC target: < 0.36
1.48 0.12 0.02 0.01 1.24 0.26 0.13 0.37 0.49 0.28 0.51 0.06
HBIPS-5:Percept of patients with appropriate justification for discharge on multiple antipsychotic medications.TJC target: 81%
0% N/A* 100% 0% 0% 100% N/A* 100% 100% 100% 100% 100%
*No patients were discharged on multiple antipsychotics this month
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JOINT COMMISSIONNote: TJC targets typically run approximately 6 months behind, the TJC targets above were for September 2017.
Contract Performance Indicators
TJC LD.04.03.09 The same level of care should be delivered to patients regardless of whether services are provided directly by the hospital or through contractual agreement. Leaders provide oversight to make sure that care, treatment, and services provided directly are safe and effective. Likewise, leaders must also oversee contracted services to make sure that they are provided safely and effectively.
3Q2018 ResultsContractor Program Administrator Summary of Performance
Amistad Peer Support Services Rodney BouffardSuperintendent
One indicator did not meet the standard: Attendance by Peer Support Staff at Treatment Team Meetings. All other indicators met or exceeded standards.
Atlantic Staffing Dr. Benjamin GrassoActing Clinical Director
All indicators exceeded standards.
Community Dental, Region II Dr. Benjamin GrassoActing Clinical Director
All indicators exceeded standards.
Comprehensive Pharmacy Services
Dr. Benjamin GrassoActing Clinical Director
All indicators met standards.
Comtec Security Richard LevesqueDirector of Support Services
All indicators met standards.
Cummins Northeast Richard LevesqueDirector of Support Services
All indicators met standards.
Disability Rights Center Rodney BouffardSuperintendent
All indicators met standards.
G & E Roofing Richard LevesqueDirector of Support Services
Indicator exceeded standards.
Goodspeed & O’Donnell Dr. Benjamin GrassoActing Clinical Director
Indicator exceeded standards.
Liberty Healthcare – After Hours Coverage
Dr. Benjamin GrassoActing Clinical Director
All indicators exceeded standards.
Liberty Healthcare – Physician Staffing
Dr. Benjamin GrassoActing Clinical Director
All indicators met or exceeded standards.
Linda Learned – OT Consultant Janet BarrettRehab Services Director
Contract evaluation not received from Program Administrator.
Maine General Community Care/HealthReach
Dr. Benjamin GrassoActing Clinical Director
All indicators met standards.
Main Security Surveillance Richard LevesqueDirector of Support Services
One indicator did not meet the standard: All points of the key card server are assessed by the vendor monthly.
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JOINT COMMISSIONAll other indicators met standards.
Contractor Program Administrator Summary of Performance
MD-IT Transcription Service Samantha BrockwayMedical Records Administrator
All indicators met standards.
Mechanical Services Richard LevesqueDirector of Support Services
No services were provided during this timeframe.
Medical Staffing and Services of Maine
Dr. Benjamin GrassoActing Clinical Director
All indicators exceeded standards.
Nordx Dr. Benjamin GrassoActing Clinical Director
One indicator did not meet standard: Timeliness of Critical Results. Action plan has already taken place. All other indicators met standards.
Norris Richard LevesqueDirector of Support Services
No services were provided during this timeframe.
Otis Elevator Richard LevesqueDirector of Support Services
All indicators met standards.
Pine Tree Legal Assistance Dr. Benjamin GrassoActing Clinical Director
Indicator exceeded standards.
Project Staffing Cindy MichaudBusiness Services Manager
All indicators exceeded standards.
Securitas Security Services Philip TricaricoSafety Compliance Officer
All indicators met or exceeded standards.
Tri-State Staffing Solutions Dr. Benjamin GrassoActing Clinical Director
All indicators exceeded standards.
UniFirst Corporation Debora ProctorExecutive Housekeeper
One indicator did not meet standard: Infection control measures taken at the provider’s facility. All other indicators met standards.
Waste Management Debora ProctorExecutive Housekeeper
All indicators met standards.
Worldwide Travel Staffing Renee PfingstDirector of Nursing
All indicators met standards.
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JOINT COMMISSIONAdverse 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 1Q2018 2Q2018 3Q2018 4Q2018 YTD
National Patient Safety Goals
Goal 1: Improve the accuracy of Patient Identification.
Capital Community Dental Clinic assures accurate patient identification by asking the patient to state his/her name and date of birth.
A time out will be taken before the procedure to verify location and numbered tooth. The time out section is in the progress notes of the patient chart. This page will be signed by the Dental as well as the Dental Assistant.
July100%4/4
Oct100%4/4
Jan100%5/5
100%31/31
Aug100%1/1
Nov10054/4
Feb100%3/3
Sept100%2/2
Dec100%4/4
Mar100%4/4
Total100%7/7
Total100%12/12
Total100%12/12
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JOINT COMMISSIONDental Clinic Post Extraction Prevention of Complications and Follow-up
Indicators 1Q2018 2Q2018 3Q2018 4Q2018 YTD
1. All patients with tooth extractions will be assessed and have teaching post procedure on the following topics, as provided by the Dentist or Dental Assistant: Bleeding Swelling Pain Muscle soreness Mouth care Diet Signs/symptoms of infection
2. The patient, post procedure tooth extraction, will verbalize understanding of the above by repeating instructions given by Dental Assistant/Hygienist.
Post dental extraction patients will receive a follow-up phone call from the clinic within 24 hours of procedure to assess for post procedure complications
July100%1/1
Oct100%3/3
Jan100%2/2
100%16/16
AugN/A0/0
Nov100%1/1
Feb100%2/2
SeptN/A0/0
Dec100%4/4
Mar100%3/3
Total100%1/1
Total100%8/8
Total100%7/7
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JOINT COMMISSIONHealthcare Acquired Infections Monitoring and Management
NPSG.07.03.01 Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals.
A Hospital Acquired Infection (HAI) is any infection present, incubating or exposed to more than 72 hours after admission (unless the patient is off hospital grounds during that time) or declared by a physician, a physician’s assistant or advanced practice nurse to be a HAI.
A Present on Admission (POA) infection is any infection present, incubating or exposed to prior to admission; while on pass; during off-site medical, dental, or surgical care; by a visitor, any prophylaxis treatment of a condition or treatment of a condition for which the patient has a history of chronic infection no matter how long the patient has been hospitalized; or declared by the physician, physician’s assistant, or advanced practice nurse to be a community acquired infection.
An Idiosyncratic Infection is any infection that occurs after admission and is the result of the patient’s action toward himself or herself.
Upper Saco (5 HAI):1 Skin/Soft tissue1 Eye3 Reproductive
Upper Kennebec (6 HAI):2 Respiratory 2 UTI2 Dental
Lower Saco (1 HAI):1 Reproductive
Lower Kennebec (3 HAI):2 Skin 1 Ear
Total infections:Hospital acquired: 15Community acquired: 0
Plan: Ongoing surveillance, Hand Hygiene Blitz, Education to reduce HAI’s. No trends were identified.
Recommendations: On admittance, do a mouth care inspection to avoid dental HAI’s or concerns.
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JOINT COMMISSION
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)
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
Medication Error Rate
# of
med
icatio
n er
ror e
vent
s tha
t oc
curr
ed f
or e
very
100
0 ep
isode
s of c
are
This graph depicts the number of medication error events that occurred for every 100 episodes of care (duplicated patient count). For example, a rate of 1.6 means that two medication error events occurred for each 125 episodes of care.
The following graphs depict the number of medication error events that occurred for every 100 episodes of care (duplicated patient count) stratified by forensic or civil classifications. For example, a rate of 1.6 means that two medication error events occurred for each 125 episodes of care. The hospital-wide results from Dorothea Dix are compared to the civil population results at Riverview due to the homogeneous nature of these two sample groups.
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Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
0.50
1.00
1.50
2.00
2.50
Medication Error RateForensic Patients
# of
med
icatio
n er
ror e
vent
s tha
t oc
curr
ed f
or e
very
100
0 ep
isode
s of c
are
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
0.50
1.00
1.50
2.00
2.50
Medication Error RateCivil Patients
# of
med
icatio
n er
ror e
vent
s tha
t oc
curr
ed f
or e
very
100
0 ep
isode
s of c
are
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Medication Variances
Medication variances are classified according to four major areas related to the area of service delivery. The error must have resulted in some form of variance in the desired treatment or outcome of care. A variance in treatment may involve one incident but multiple medications; each medication variance is counted separately irrespective of whether it involves one error event or many. Medication error classifications include:
Prescribing: An error of prescribing occurs when there is an incorrect selection of drug, drug dose, dosage form, quantity, route, concentration, rate of administration, or instructions for use of a drug product ordered or authorized by physician or another legitimate prescriber. Errors may occur due to improper evaluation of indications, contraindications, known allergies, existing drug therapy and other factors. Illegible prescriptions or medication orders that lead to patient level errors are also defined as errors of prescribing in identifying and ordering the appropriate medication to be used in the care of the patient.
Dispensing: An error of dispensing occurs when the incorrect drug, drug dose or concentration, dosage form, or quantity is formulated and delivered for use to the point of intended use.
Administration: An error of administration occurs when there is an incorrect selection and administration of drug, drug dose, dosage form, quantity, route, concentration, rate of administration, or instructions for use of a drug product ordered or authorized by physician or another legitimate prescriber.
Complex: An error which resulted from two or more distinct errors of different types is classified as a complex error.
Review, Reporting and Follow-up Process:The Medication Variances Process Review Team (PRT) meets weekly to evaluate the causation factors related to the medication variances reported on the units and in the pharmacy and makes recommendations, through its multi-disciplinary membership, for changes to workflow, environmental factor, and patient care practices. The team consists of the Clinical Director (or designee), the Director of Nursing (or designee), the Director of Pharmacy (or designee), and the Clinical Risk Manager or the Performance Improvement Manager.
The activities and recommendations of the Medication Variances PRT are reported monthly to the Integrated Performance Excellence Committee.
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JOINT COMMISSION
Administration ProcessMedication Errors Related to Staffing Effectiveness
3Q2018
Date Omit Type of ErrorFloa
t New O/T Unit Staff Mix
RN LPN1/28/2018 N Wrong Medication N N N LKSCU UNK UNK3/29/2018 N Wrong Patient Y Y N LKMAIN 4 03/29/2018 N Wrong Patient Y Y N LKMAIN 4 03/29/2018 N Wrong Patient Y Y N LKMAIN 4 03/29/2018 N Wrong Patient Y Y N LKMAIN 4 03/29/2018 N Wrong Patient Y Y N LKMAIN 4 0
Totals 0 6
Total Errors
5 5 0LS: 0
US: 0
LK:6
UK: 0
Percent 0% 83% 83% 0% 0% 0%100% 0%
*Each dose of medication is documented as an individual variance (error)
52
Type of Error # of ErrorsWrong Medication 1Wrong Patient 5Total 6
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JOINT COMMISSIONInpatient Consumer Survey
TJC PI.01.01.01 EP16: The hospital collects data on the following: Patient perception of the safety and quality of care, treatment, and services.
The Inpatient Consumer Survey (ICS) is a standardized national survey of customer satisfaction. The National Association of State Mental Health Program Directors Research Institute (NRI) collects data from state psychiatric hospitals throughout the country in an effort to compare the results of patient satisfaction in six areas or domains of focus. These domains include Outcomes, Dignity, Rights, Participation, Environment, and Empowerment.
Inpatient Consumer Survey (ICS) has been recently endorsed by NQF, under the Patient Outcomes Phase 3: Child Health and Mental Health Project, as an outcome measure to assess the results, and thereby improve care provided to people with mental illness. The endorsement supports the ICS as a scientifically sound and meaningful measure to help standardize performance measures and assures quality of care.
Rate of Response for the Inpatient Consumer Survey:
Due to the operational and safety need to refrain from complete openness regarding plans for discharge and dates of discharge for forensic patients, the process of administering the inpatient survey is difficult to administer. Whenever possible, Peer Support staff work to gather information from patients on their perception of the care provided to then while at Riverview Psychiatric Center.
The Peer Support group has identified a need to improve the overall response rate for the survey. This process improvement project is defined and described in the section on Patient Satisfaction Survey Return Rate of this report.
There is currently no aggregated date on a forensic stratification of responses to the survey.
Note: When the Riverview field is blank for a month it means that no patients responded to the survey questions on that page in that particular month.
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Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.0010.0020.0030.0040.0050.0060.0070.0080.0090.00
100.00
Patient Survey Outcome of Care Domain
% o
f pati
ents
with
pos
itive
resp
onse
s
Outcome Domain Questions:1. I am better able to deal with crisis.2. My symptoms are not bothering me as much.3. I do better in social situations.4. I deal more effectively with daily problems.
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Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
Patient SurveyDignity Domain
% o
f pati
ents
wih
t pos
itive
resp
onse
s
Dignity Domain Questions:1. I was treated with dignity and respect.2. Staff here believed that I could grow, change and recover.3. I felt comfortable asking questions about my treatment and medications.4. I was encouraged to use self-help/support groups.
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Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
Patient SurveyRights Domain
% o
f pati
ents
with
pos
itive
resp
onse
s
Rights Domain Questions:1. I felt free to complain without fear of retaliation.2. I felt safe to refuse medication or treatment during my hospital stay.3. My complaints and grievances were addressed.
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Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
Patient Survey Participation in Treatment Domain
% o
f pati
ents
with
pos
itive
resp
onse
s
Participation Domain Questions:1. I participated in planning my discharge.2. Both I and my doctor or therapists from the community were actively involved in my hospital
treatment plan.3. I had an opportunity to talk with my doctor or therapist from the community prior to discharge.
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Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
Patient SurveyFacility Environment Domain
% o
f pati
ents
with
pos
itive
resp
onse
s
Environment Domain Questions:1. The surroundings and atmosphere at the hospital helped me get better.2. I felt I had enough privacy in the hospital.3. I felt safe while I was in the hospital.4. The hospital environment was clean and comfortable.
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Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar4Q2017 1Q2018 2Q2018 3Q2018
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
Patient SurveyEmpowerment Domain
% o
f pati
ents
with
pos
itive
resp
onse
s
Empowerment Domain Questions:1. I had a choice of treatment options.2. My contact with my Doctor was helpful.3. My contact with nurses and therapists was helpful.
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JOINT COMMISSIONFall Reduction Strategies
TJC PI.01.01.01 EP38: The hospital evaluates the effectiveness of all fall reduction activities including assessment, interventions, and education.
TJC PC.01.02.08: The hospital assesses and manages the patient's risks for falls.EP01: The hospital assesses the patient’s risk for falls based on the patient population and setting.EP02: The hospital implements interventions to reduce falls, based on the patient’s assessed risk.
Type of Fall by Patient and Month
Fall Type Patient January February March 3Q2018
Un-witnessed
MR16* 1 1MR107 1 1MR8134* 1 1
MR8138 1 1Totals 1 1 2 4
Fall Type Patient January February March 3Q2018
Witnessed
MR16* 1 1 1 3MR83 1 1MR89 1 1MR7900 1 1MR8080 1 1MR8116 1 1MR8134* 1 1
Totals 2 4 3 9
*Indicates that the patient had both un-witnessed and witnessed falls in the 3Q2018.
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JOINT COMMISSION
Admissions
Responsible Party: Samantha Newman, RN, Admissions Nurse
Number of Admissions:
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JOINT COMMISSION
Average Number of Wait Days:
WAIT DAYS JULY AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUNE AVGCIVIL: 7 13 12 9 12 13 25 22 8 13VOL 0 2 1CIVIL-INVOL 6 7 4 2 3 1 3 5 5 4DCC 12 18 14 10 14 16 27 26 20 17DCC-PTP 1 1 0 1 1 1FORENSIC: 7 14 16 13 9 11 21 7 20 1360 DAY EVAL 10 17 23 14 11 19 26 10 12 16JAIL TRANS 31 9 6 16 14 84 27IST 6 14 6 11 12 8 10NCR 0 0 0 0 0 0 0 0 0AVERAGE 7 13 13 11 11 12 23 15 13 13
*If a field is blank it means that there were no admissions for that legal status during that timeframe
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QUALITY ASSURANCE & PERFORMANCE IMPROVEMENT
Number of Discharges:
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QUALITY ASSURANCE & PERFORMANCE IMPROVEMENT
Average Length of Stay (Days):
ALOS JULY AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUNE AVGCIVIL: 121 66 67 43 68 112 95 89 73 82VOL 49 49CIVIL-INVOL 343 39 67 84 133 40 152 90 119DCC 128 84 77 43 74 92 100 83 81 85DCC-PTP 43 19 29 21 145 7 44FORENSIC: 83 119 194 149 157 64 103 175 121 12960 DAY EVAL 27 56 30 29 88 38 56 50 57 48JAIL TRANS 2 139 84 28 8 52IST 380 214 194 464 312 138 193 94 31 224NCR 11 180 415 43 31 47 778 214 215AVERAGE 111 86 119 121 108 99 98 134 88 107
*If a field is blank it means that there were no discharges for that legal status during that timeframe
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QUALITY ASSURANCE & PERFORMANCE IMPROVEMENT
I. Measure Name: NCR Admissions
Measure Description: Admittance of all NCR patients within 24 hours of referral
Type of Measure: Quality Assurance
ResultsUnit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Target NCR referrals admitted within 24
hours
4Q2017100%5/5
100% 100% 100% 100% 100%
Actual 100%4/4
100%6/6
100%4/4
100%14/14
Data Analysis: There were four NCR admissions this quarter, all four were admitted on the day of referral.
Action Plan: Continue to gather data on wait days for NCR admissions. Keep one bed available on the Forensic unit for NCR admissions when possible.
January 2018 February 2018 March 2018 3Q2018# of NCR Admissions 0 3 1 4Average Wait Days N/A 0 0 0
II. Measure Name: Jail Transfer Bed
Measure Description: Keep one Jail Transfer bed open and track length of stay and legal outcomes.
Type of Measure: Performance Improvement
ResultsUnit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
TargetJail Transfer
Beds
4Q2017100%2/2
100% 100% 100% 100% 100%
Actual N/A 100%4/4
100%5/5
100%9/9
Data Analysis: There were five Jail Transfers admitted this quarter.
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QUALITY ASSURANCE & PERFORMANCE IMPROVEMENT
January 2018 February 2018 March 2018 3Q2018# of Jail Transfer Admissions 2 2 1 5# of Jail Transfer Discharges 1 2 0 3
III. Measure Name: Off Shift Admission Paperwork
Measure Description: All required documentation will be complete and accurate for admissions on the off shifts
Type of Measure: Performance Improvement
ResultsUnit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Target Percent of assessments completed
on time
FY201775%
100% 100% 100% 100% 100%
Actual N/A N/A 100%1/1
100%1/1
Data Analysis: One civil patient was admitted afterhours. All paperwork was completed within 24 hrs by the nurse and PA.
Action Plan: Continue to monitor data so paperwork is completed accurately and timely.
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QUALITY ASSURANCE & PERFORMANCE IMPROVEMENT
Capital Community Dental Clinic
Responsible Party: Dr. Ingrid Prikryl, DMD
I. Measure Name: Yearly Periodontal Charting
Measure Description: Complete a full mouth periodontal charting.
Type of Measure: Performance Improvement
Results
Unit Baseline 1Q2018 2Q2018 3Q2018 4Q201
8 YTD
Target % of recall appointments where full
mouth periodontal charting was completed
FY201662%
60% 65% 70% 75% 75%
Actual74%
139/188
80%113/14
2
98%126/12
9
76%252/33
0
Data Analysis: Patients are being very receptive to having perio-charting done yearly. Hygienists are remembering to ask patients and are encouraging them to have it done.
1Q2018: 139/188 = 74% 3Q2018: 126/129 = 98%July 2017 42/54 = 78% January 2018 38/39 = 97%August 2017 44/68 = 65% February 2018 45/47 = 96%September 2017 53/66 = 80% March 2018 43/43 = 100%
2Q2018: 113/142 = 80% 4Q2018:October 2017 47/60 = 78% April 2018 November 2017 33/40 = 83% May 2018December 2017 33/42 = 79% June 2018
Action Plan: To get a more accurate percentage, charting will be completed by the hygienist during prophy appointments only and not during emergency or new patient appointments.
Comments: Definite improvement throughout the year.
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QUALITY ASSURANCE & PERFORMANCE IMPROVEMENT
II. Measure Name: Improving Oral Hygiene
Measure Description: Monitoring and working to improve patients’ oral hygiene
Type of Measure: Performance Improvement
Results
Unit Baseline 1Q2018 2Q2018 3Q2018 4Q201
8 YTD
TargetRecall Hygien
e Prophy
FY201748%
65% 65% 65% 65% 65%
Actual51%
139/273
48%109/22
8
50%102/20
6
50%350/70
7
Data Analysis: Percentage of patients with Excellent and Good Hygiene. The goal is to stay above 65% and continuously improve to 75%.
1Q2018: 139/273 = 51% 3Q2018: 102/206 = 50%July 2017 40/75 = 53% January 2018 22/66= 33%
August 2017 49/99 = 49% February 2018 41/63 = 65%September 2017 50/99 = 51% March 2018 39/77 = 51%
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2Q2018: 109/228 = 48% 4Q2018:October 2017 50/96 = 52% April 2018November 2017 39/66 = 59% May 2018December 2017 20/66 = 30% June 2018
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QUALITY ASSURANCE & PERFORMANCE IMPROVEMENT
III. Measure Name: Next Visit
Measure Description: Writing Next Visit in progress note.
Type of Measure: Quality Assurance
Results
Unit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Target # of progress
notes with next visit
documented
FY201695%
90-100% 90-100% 100% 100% 100%
Actual 100%20/20
95%19/20
100%20/20
98%59/60
Data Analysis: This continues to be a good quality assurance measure.
1Q2018: Yes: 20 No: 0 3Q2018: Yes: 20 No: 02Q2018: Yes: 19 No: 1 4Q2018: Yes: No:
Action Plan: Write at the end of every progress note what the next visit is going to be even if it is a three MRC or denture adjustment as needed.
Comments: Data is collected from quarterly reviews by Community Dental. 20 random charts were evaluated.
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QUALITY ASSURANCE & PERFORMANCE IMPROVEMENT
IV. Measure Name: RMH and MEDS
Measure Description: Review medical history and medications at the start of each appointment
Type of Measure: Quality Assurance
ResultsUnit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
TargetNoted Daily
ReviewedQuarterly
FY2016100%
90-100% 90-100% 100% 100% 100%
Actual 100%20/20
100%20/20
100%20/20
100%60/60
Data Analysis: Patients are given their history and medication list to review prior to their appointment. Medical history and medication lists are reviewed with the patient at each appointment.
1Q2018: Yes: 20 No: 0 3Q2018: Yes: 20 No: 02Q2018: Yes: 20 No: 0 4Q2018: Yes: No:
Action Plan: Continue to review patient medical history and medication list at the start of each appointment.
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QUALITY ASSURANCE & PERFORMANCE IMPROVEMENT
Comments: Data is collected from quarterly reviews by Community Dental. 20 random charts were evaluated.
V. Measure Name: Blood Pressure
Measure Description: Blood pressure and pulse taken at each dental appointment
Type of Measure: Quality Assurance
ResultsUnit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Target Noted
Daily; Reviewed Quarterly
FY201795%
90-100% 90-100% 100% 100% 100%
Actual 95%19/20
95%19/20
100%20/20
97%58/60
Data Analysis: Blood Pressure is taken on all patients seen for restorations, because of the use of an anesthetic, and prophy appointments prior to the appointment; denture patients do not always have their blood pressure taken, especially on denture deliveries.
1Q2018: Yes: 19 No: 1 3Q2018: Yes: 20 No: 02Q2018: Yes: 19 No: 1 4Q2018: Yes: No:
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Action Plan: Need to discuss with Hygienists who work on Friday, that BP needs to be taken on all dental patients. Continue to take blood pressure and pulse at the start of all dental appointments. To withstand dental care, blood pressure should be less than 160/90.
Comments: Data is collected from quarterly reviews. Twenty random charts were evaluated.
VI. Measure Name: Treatment Plan
Measure Description: Updating treatment plan yearly
Type of Measure: Performance Improvement
ResultsUnit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Target Checked
Monthly; Reviewed Quarterly
New Measure
90-100% 90-100% 100% 100% 100%
Actual 95%19/20
100%20/20
100%20/20
98%59/60
Data Analysis: This is a new measure for FY2018. Patients not showing up for their recall appointments may make this difficult.
1Q2018: Yes: 19 No: 1 3Q2018: Yes: 20 No: 02Q2018: Yes: 20 No: 0 4Q2018: Yes: No:
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QUALITY ASSURANCE & PERFORMANCE IMPROVEMENT
Action Plan: Evaluate treatment plans for completeness and update yearly.
Comments: Data is collected from quarterly reviews by Community Dental. 20 random charts will be evaluated every three months.
VII. Measure Name: Infection Control
Measure Description: Instruments are checked with each load
Type of Measure: Quality Assurance
ResultsUnit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Target Noted
Daily; Reviewed Quarterly
New Measure
100% 100% 100% 100% 100%
Actual 100%139/139
100%152/152
100%136/136
100%427/427
Data Analysis: To insure safety to our patients and staff, each load is checked prior to release of instruments for proper sterilization.
1Q2018: Pass: 139 Fail: 0 3Q2018: Pass: 136 Fail: 0
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2Q2018: Pass: 152 Fail: 0 4Q2018: Pass: Fail:
Action Plan: After each sterilization cycle, the dental staff checks steam indicator on each pouch and Steam SAFE and records PASS or FAIL onto the log. These results are reviewed daily and discussed at monthly staff meetings, and recorded in quarterly reports.
Comments: If a fail occurred, it would be given immediate attention.
VIII. Measure Name: Darkroom Test
Measure Description: Efficiency of the darkroom and safe light (red light)
Type of Measure: Quality Assurance
ResultsUnit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Target Tested
Monthly; Reviewed Quarterly
New Measure
100% 100% 100% 100% 100%
Actual 100% 100% 100% 100%
Data Analysis: To insure the efficiency of the darkroom during processing.
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1Q2018: 3Q2018:July 2017: PASS January 2018: PASSAugust 2017: PASS February 2018: PASSSeptember 2017: PASS March 2018: PASS
2Q2018: 4Q2018:October 2017: PASS April 2018: November 2017: PASS May 2018: December 2017: PASS June 2018:
Action Plan: Checking to be sure red safe light is illuminated every time someone utilizes the darkroom.
Dietetic Services
Responsible Party: Kristen Piela, RDN, LDN, Dietetic Services Manager
I. Measure Name: Infection Control
Measure Description: The Food Service Manager or designee will verify completion of sanitation processes for eighteen specified pieces foodservice equipment. Validation will occur with the use of a Sanitation Schedule and Checklist. This will ensure equipment is clean and sanitary. Dietetic Services workers will be responsible for cleaning and documenting the completion of each task. The supervisor will review the sheets and complete a sanitation inspection of the kitchen equipment on a weekly basis.
Type of Measure: Performance Improvement
Results
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Unit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Target Percentage of
equipment cleaned as assigned
1Q201765%
70% 75% 80% 90% 90%
Actual 80%129/162
83%135/162
82%132/162
81%396/486
Data Analysis: Data analysis by month indicates a high of 87% in January, a low of 74% in February, and 83% in March.
Action Plan: Food Service Manager will assure all Cook III’s maintain supervision of the completion of all the cleaning tasks and will assure cleaning duties are distributed to others to account for the Cook II vacancy. Cook III’s will supervise cleaning routines, review the Master Cleaning Schedule daily to assure that staff has allotted time within their work day to complete specific cleaning assignments, will review departmental infection control procedures mandated by federal regulations: FDA food code, CMS, TJC, etc.; and will review this report in a general staff meeting in April.
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II. Measure Name: Clinical Nutrition: Patient Satisfaction
Measure Description: A survey is used to assess patient foodservice satisfaction. Results of these surveys will be used to identify the lowest scoring areas of foodservice. Interventions will be implemented to address the areas of needed improvement.
Type of Measure: Performance Improvement
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Data Analysis: Analysis of the patient satisfaction surveys reveals there is room for improvement regarding the friendliness of foodservice staff as well as the overall taste of food. Conversely, patients appear to understand the diets that they have been prescribed, despite their distaste of the food, the overall appearance is rated above a 4.1.
Action Plan: Food Service Manager will review these findings with the Cook III’s and will attend prime vendor food show for healthy new snack options. Cook III’s will provide a snack rotation including a variety of items as available, will provide training on customer service, and will review and explain this report in a general staff meeting in April.
Additional Patient Comments: 1. “We need better snacks.”2. “I want more food. I do not need to be on a carbohydrate reduced diet. I am a big guy. Your
staff refuse to give me more food.”3. “Happy to have milk at all meals. Enjoying fresh fruit. A couple of your staff are not happy
workers.”4. “Some foods on the trays are cold, but overall the food is better than we get in jail.”5. “You have great meals here.”6. “The help (employees) are excellent. They can't be more accommodating to each person.”7. “Thank you for feeding me.”
III. Measure Name: Nutrition Screen Accuracy
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Measure Description: The Registered Dietitian will review every patient’s Nursing Admission Data upon admission to assess ongoing compliance with the accuracy of the Nutrition Screen tool. This screen is utilized to attain nutrition indicators that necessitate dietary intervention.
Type of Measure: Quality Assurance
ResultsUnit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Target Percent of Nutrition screens
completed accurately
FY201693%
161/173
93% 95% 97% 100%
Actual 88%51/58
74%45/61
87%54/62
83%150/181
Data Analysis: These results indicate there has been a 13% increase in the accuracy of the information gathered on the nutrition screen this quarter. The nutrition screen is completed by the nurse responsible for the admission. Data analysis indicates that 7 of the 8 inaccurately documented nutrition screens were completed by the same admitting nurse. Seven of the screens should have noted a BMI>29, one screen did not indicate the patient’s recent alcohol abuse, and one screen did not indicate the patient’s current medication: lithium. Action Plan: The Dietetic Services Manager spoke with the Director of Nursing regarding these results. The DON stated that the nutrition screen has been placed on the medical treatment plan audit. The Dietetic Services Manager spoke with the admitting nurse responsible for the majority of the >29 BMI omissions. A plan was set in place to use the pre-admission height and weight to obtain the BMI at admission.
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IV. Measure Name: Hand Hygiene Compliance
Measure Description: Supervisory staff including the Food Service Manager and Cook III’s will observe all dietary employees as they return from break for proper hand hygiene.
Type of Measure: Quality Assurance
ResultsUnit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Target Percent of Dietary
employees washing
hands after break
FY201696%
95% 96% 98% 100% 100%
Actual 82%312/381
89%500/565
89%471/528
87%1283/1474
Data Analysis: The submitted data portrays neither an increase or decrease in compliance. All employees were observed between 22-60 times this reporting period. Two of the twelve employees do not consistently wash their hands when returning from break. There were two observers this quarter.
Action Plan: Dietetic Services Manager reviewed this data with the Food Service Manager.
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Food Service Manager will observe hand hygiene compliance at unannounced intervals throughout the next reporting quarter.
Provide a monthly review of the data and post as a reminder of its connection to infection control
Provide a review of the proper hand washing times and techniques to the identified employees who are not consistently washing their hands after break.
Incorporate hand hygiene training into the departmental new employee orientation. Provide a review of the proper and washing times and techniques as quarterly training. Encourage front line supervisors to promote hand hygiene with their staff throughout the day. Provide this Quality Assurance measure for review by staff to highlight the continued success.
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Emergency Management
Responsible Party: Robert Patnaude, Emergency Management Coordinator
I. Measure Name: Communications Equipment/Two-way radiosThe Joint Commission states the following in EM.02.02.01: “As part of its Emergency Operations Plan, the hospital prepares for how it will communicate during emergencies. The hospital maintains reliable communications capabilities for the purpose of communicating response efforts to staff, patients, and external organizations.” The Centers for Medicare & Medicaid Services (CMS), Emergency Preparedness Requirements states the following in A-0701 §482-41(a) Standard: Buildings, “prepares to ensure the safety and well-being of staff and patients by establishing a stepped-up capacity and capability with regard to a communications plan that assures that the facility can coordinate patient care and establish response communications to staff, patients and external entities”.
In the event of an unforeseen emergency which could impact the safety and security of patients, staff, and visitors at Riverview Psychiatric Center and its’ remote-care site, Outpatient Services, communications equipment, more specifically, two-way radios are a major solution to getting accurate information to and from staff in a timely manner. The objective of the Emergency Management Communications PI is to ensure compliance with the Joint Commission and CMS standards by ensuring that staff employ and respond in a timely and appropriate manner utilizing the two-way radio system.
Type of Measure: Performance Improvement
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Methodology: Each month, the Emergency Management Coordinator or designee will perform a combination of partial and hospital-wide radio drills. Such drills will utilize a specific form to track the drills (see attached). In conjunction with the drills, environmental rounds will be conducted for the purpose of inspecting communications equipment. Any deficiencies shall have the appropriate corrective measure immediately instituted until compliance is met.
The numerator is the number of timely and appropriate responses by staff utilizing the two-way radios by assignments. The denominator will be the total number of two-way radios by assignments.
Baseline Data: To assure that critical emergency information is disseminated in a timely and accurate manner, a minimum of 90% compliance has been established. This data will be reported monthly to the Emergency Management Committee, IPEC, and the Environment of Care (EOC) Committee. Areas that fail to meet the threshold will be immediately reported to the committees.
ResultsUnit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Target Percent of timely and
appropriate responses
NewestFY2018
90%250/276
91%
90% 90% 90% 90% 90%
Actual 94%65/69
98%203/207
95%197/207
96%465/483
Data Analysis: With a significant amount of hands-on demonstrations, radio tests, and an increase in the use of radios, data showed that majority of the radios are being deployed in a timely manner and that staff is familiar with operating the radio.
Riverview’s programs are supported and dependent on (2) two-way radios across all disciplines. Staff from all departments continues to receive education on radio etiquette and protocol through one-on-one instruction and hospital-wide emails. Based on the occurrences listed here, the Emergency Management Coordinator felt that these educational programs augment the objectives sought after during the typical monthly radio drills.
The use and additional deployment of radios such as the Command Room and the BERT Program has enhanced the communications abilities geared towards an “all hazards” approach along with the daily operational needs. There seems to be a decrease of times that staff do not follow the proper radio etiquette. Some radio damage is reported due to carelessness in carrying the radios. These occurrences
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have been addressed through unit supervisors. Overall, staff has done a great job in securing the radios and utilizing them during BERT (Behavioral), CODE BLUE (Medical) responses, and activities such as fresh air breaks. We have also deployed additional radios to Security to be assigned by them to staff who accompany patients on walks while on grounds’.
Since the use of the radios in the everyday operations of the hospital is critical and there is, at times, a fair number of new staff, the Emergency Manager, in agreement with the Director of Support Services and the Director of Quality Improvement, has elected to continue this Performance measure.
After a comprehensive review of the locations of two-way radios and the impact that those locations may have on the communications during normal and emergency operations at the facility and its remote-care site, Outpatient Services, we will be adding a third radio on each of the Main patient care units and have recently added two additional radios at Security for staff-patient on-ground walks.
During 3Q2018, we have seen an increase in the damage to radios from being dropped which primarily has damaged the battery guides which keeps the battery tight to the chassis. This damage has affected the charging of the radio or the transmission of the radio during tests and call-ins. We are currently looking at changing some radios out with a different style or placing the radios in a protective case of some sort. Also during 3Q2018, the Emergency Management Coordinator has seen a significant improvement in radio etiquette. This is a result of various disciplines, immediately after hearing unacceptable radio transmissions, reminding involved staff to refrain from such use of the radio.
Special Note:
1. Information contained within the “AREAS/GROUPS MONITORED” is fluid at times and any changes shall reflect the addition or deletion of two-way radios for those areas.
2. Recently, it was discovered that a possible lightning strike caused some damage to our repeater radio housed in the Saco Penthouse in addition to damage to the coax cable and arrester. This damage resulted in a minimal loss of transmit and receive capabilities. All of the affected equipment has been replaced. An evaluation of the physical structure to all the components of the communication system with regard to the protection from such events by design concludes that the system is well protected and that no modifications need to be made.
Action Plan: 1. Continue tests and remedial training to staff along with supporting handouts as needed. 2. Increased surveillance of mass notification equipment such as alert pagers.3. Continue to look at various media to notify staff to employ radios.
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4. Continue to send out periodic educational information through the email system and to ensure that orientation covers all the components of this Quality Assessment and Performance Improvement Program.
5. Yearly, conduct a comprehensive review of the locations of two-way radios and the impact that those locations may have on the communications during normal and emergency operations at the facility and its remote-care site, Outpatient Services.
6. Purchase and add a third BERT radio on each unit since extensive time of the radio charger may affect the performance of the radio, especially as seen with the newer Baofeng radios.
7. Investigate the various styles of radio that may be more resilient to commercial use in this type of environment thereby lessening or eliminating damage as a result of a radio being dropped.
8. In *4 and *9 as stated below, the radios were repaired, tested, and returned to service.
AREAS/GROUPS MONITORED JUL
2017AUG2017
SEP2017
OCT2017
NOV2017
DEC2017
JAN2018
FEB2018
MAR2018
APR2018
MAY2018
JUN2018n=numerator
d= denominatorPATIENT CARE AREAS/# of radiosJOB COACH/1 1/1 *** *** 1/1 1/1 1/1 1/1 1/1 0/1*7OUT-PATIENT SERVICES/1 1/1 *** *** 1/1 1/1 1/1 1/1 1/1 1/1
TX MALL, CLINIC, DIETARY, MED RECORDS/5
5/5 *** *** 5/5 5/5 5/5 5/5 5/5 5/5
US, UK, LS, LSSCU, LK, LKSCU/10
18/20*2 *** *** 20/20 19/20
**218/20
**216/20
*419/20
*619/20
*8
SUPPORT SERVICES/# of radios
ADMINISTRATION/4 3/4*3 *** *** 4/4 4/4 4/4 4/4 4/4 4/4
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HOUSEKEEPING/ 15
14/15*1 *** *** 15/15 14/15
**1 15/15 14/15*5 15/15 14/15
*9MAINTENANCE/ SUPPORT/14 14/14* *** *** 14/14* 14/14* 14/14* 14/14 14/14 14/14
NOD/1 1/1 *** *** 1/1 1/1 1/1 1/1 1/1 1/1NURSING SERVICES/1 1/1 *** *** 1/1 1/1 1/1 1/1 1/1 1/1
OPERATIONS/1 1/1 *** *** 1/1 1/1 1/1 1/1 1/1 1/1SECURITY/5 5/5 *** *** 5/5 5/5 5/5 5/5 5/5 5/5STATE FORENSIC SERVICES/1 1/1 *** *** 1/1 1/1 1/1 1/1 1/1 1/1
PATIENT CARE AREAS 25/27 *** *** 27/27 26/27 25/27 22/27 26/27 25/27
SUPPORT SERVICES 40/42 *** *** 42/42 41/42 42/42 41/42 42/42 41/42
TOTAL 65/69 *** *** 69/69 67/69 67/69 63/69 68/69 66/69
* Some radio units not on duty due to shift assignment therefore given same weight in order not to have a negative impact. EMC: Emergency Management Coordinator
*1 One housekeeper reported that their radio was not working. The radio needed to be reprogrammed. After reprogramming, the test was performed as expected.
*2 a. LS-2 did not transmit since the battery was not seated properly due to the radio being dropped resulting in a cracked battery. Battery was replaced by the EMC.
b. US-Bert-1 was not transmitting during BERT call. Discovered that the radio battery may have diminished to the point the programming was affected. Plan to add an additional BERT radio on each unit to give adequate charge time to the BERT radios. EMC to assign an additional BERT radio on each Main unit.
*3 One Administration radio was not deployed since the pager assigned to that unit did not function due to a dead battery. Battery changed.
*4 (1) Bert radio reprogrammed. (1) radio battery failed. (2) radios had to have battery changed since there was damage to the battery or case and did not allow the battery to maintain a good contact in the charger.
*5 (1) Housekeeping radio battery had prongs that had been broken off and would not hold the battery tight in the chassis. New battery installed.
*6 (1) Lower Saco battery was not holding charge. Changed out. *7 Job Coach radio not holding charge. Operational needs being assessed. Will possibly replace
the entire radio due to age. Will report on the next report.
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*8 (1) “Staff Walk” radio reprogrammed and returned to service. (1) Lower Saco radio front replaced since it had been dropped.
*9 (1) Housekeeping radio not holding in place. Had been dropped. Changed out.
**1 One housekeeper reported that their radio was not transmitting well. The radio needed to be reprogrammed. After reprogramming, the test performed as expected.
**2 a. LS-1 did not transmit since the battery was not seated properly. Radio was seated properly and education given to staff by EMC.b. UK-Bert-1 was statically during transmission. After reprogramming, the test performed as expected.
##Note: Operations base radio has been sent for repair. Radio in EM office placed in Operations until a determination is made as to the status of the radio.
***Notes: 1. August and September of 1Q were not reported by error. 2. As reported the last quarter, we have received more BERT radios and are in the process of
adding 1 more to each unit.
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Harbor Treatment Mall
Responsible Party: Janet Barrett CTRS, Director of Rehabilitation Services
I. Measure Name: Harbor Mall Hand-Off Communication (HOC)
Measure Description: To provide the exchange of patient-specific information between the patient care units and the Harbor Mall, to ensure continuity of care and safety within designated time frames. Overall Compliance Target is 100%.
Type of Measure: Performance Improvement
Objectives 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Hand-off communication sheet was received at the Harbor Mall within the designated time frame.
52%259/495
57%260/455
42%*199/480
50%718/1430
SBAR information completed from the units to the Harbor Mall.
96%476/495
98%444/455
97%465/480
97%1385/1430
Accuracy of information from the units.
91%449/495
96%436/455
90%434/480
92%1319/1430
Overall Compliance 80%1184/1485
84%1140/1365
76%1098/1440
80%3422/4290
Data Analysis: Indicator one (timeliness) down 15% from 57% to 42%, indicator two (completion) down 1% from 98% to 97%, indicator three (accuracy) down 6% from 96% to 90%, and over all percentage down 8% from 84% to 76%, with a year to date of 80%.
Action Plan: Continue daily monitoring of hand-off communication sheets to encourage accuracy, review findings of monitoring with RN4 or RN5 to address any issues or areas of concern, maintain highlighted statement at the bottom of each hand-off communication sheet to serve as visual cue to return completed accurate sheets within the designated time frame.
* We have implemented staff escorts to TX Mall which is contributing to the tardiness of HOC. Staff are waiting for patients rather than just dropping off the sheet.
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Health Information Technology (Medical Records)
Responsible Party: Samantha Brockway, RHIT, Medical Records Administrator
I. Measure Name: Documentation and Timeliness
Indicators3Q2018Findings
3Q2018Compliance Target
Records will be completed within Joint Commission standards, state requirements and Medical Staff bylaws timeframes.
There were 65 discharge charts reviewed in 3Q2018. Of those, 60 were completed within 30 days.
92% 80%
Discharge summaries will be completed within 15 days of discharge.
Out of 65 discharge summaries, 63 were completed within 15 days of discharge.
97% 100%
All forms/revisions to be placed in the medical record will be approved by the Medical Records Committee.
Seven revised forms, two new forms, and one form deleted (see minutes).
100% 100%
Medical transcription will be timely and accurate.
485 dictated reports were completed within 24 hours.
100% 90%
Data Analysis: The indicators are based on the review of sample discharged records. There was a 92% compliance with 30-day record completion. Weekly “charts needing attention” lists are distributed to medical staff, including the Medical Director, along with the Superintendent, Risk Manager and the Quality Improvement Manager. There was 100% compliance with timely & accurate medical transcription services.
Actions: Continue to monitor.
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II. Measure Name: Confidentiality
Indicators3Q2018Findings
3Q2018Compliance Target
All patient information released from the Health Information Department will meet all Joint Commission, State, Federal & HIPAA standards.
3,834 Requests for information (453 requests for patient information and 3,381 police checks) were released.
100% 100%
All new employees/contract staff will attend confidentiality/HIPAA training.
All new employees/contract staff attended confidentiality/HIPAA training.
100% 100%
Patient confidentiality/privacy issues tracked through incident reports.
1 privacy incident report.
Summary: The indicators are based on the review of all requests for information, orientation for all new employees/contract staff and confidentiality/privacy-related incident reports.
No problems were found in 3Q2018 related to release of information from the Health Information Department and training of new employees/contract staff; however, compliance with current law and HIPAA regulations need to be strictly adhered to requiring training, education and policy development at all levels.
Actions: The above indicators will continue to be monitored.
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III. Measure Name: Regulatory and Compliance Standards in DocumentationEnsuring Fiscal Responsibility in Documentation and Billing Practices
Indicator and Rationale for Selection 1Q2018 2Q2018 3Q2018 4Q2018 YTDIdentification Data 100%
63/63100%60/60
98%64/65
99%187/188
Medical History, including chief complaint; HPI; past, social & family hx.; ROS, and physical exam w/in 24 hr. conclusion and plan
95%60/63
3>24 hrs
85%51/60
9>24 hrs
82%53/65
12>24 hrs
87%164/188
24>24 hrs
Summary of patient’s psychosocial needs as appropriate to the patients *
75%47/63
16>7 days
77%46/60
14>7 days
78%51/65
14>7 days
77%144/188
44>7 daysPsychiatric Evaluation in patient’s record w/in 24 hrs. of admission
89%56/63
7>60 hrs
90%54/60
6>60 hrs
86%60/65
5>60 hrs
90%170/188
18>60 hrsPhysician (TO/VO w/in 72 hr.) 95%
111/11797%
106/10996%
137/14296%
351/368Evidence of appropriate informed consent
91%61/63
98%59/60
98%64/65
98%184/188
Clinical observations including the results of therapy.
100%63/63
100%60/60
100%65/65
100%188/188
Nursing discharge Progress Note with time of discharge departure
78%49/63
87%52/60
72%47/65
98%148/188
Consultation reports, when applicable 95%131/144
89%165/186
90%210/234
90%506/564
Advance Directive Status on admission and SW follow up after
97%61/63
100%60/60
100%65/65
99%186/188
Notice of Privacy 100%63/63
100%60/60
98%64/65
99%187/188
Chart Completion w/in 30 days of discharge date
95%60/63
98%59/60
92%60/65
95%179/188
Discharge summary completed within 30 days
79%50/63
88%53/60
97%63/65
88%%166/188
Discharge Packet sent to follow up provider within five days of discharge.
100%63/63
100%60/60
92%60/65
97%183/188
* The parameters for this measure will be changed to meet applicable goals as defined by the Director of Social Work. The current measure is more stringent than regulatory standards dictate.
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IV. Measure Name: Release of Information for Concealed Carry Permits:
Define:The process of conducting background checks on applicants for concealed carry permits is the responsibility of the two State psychiatric hospitals. Patients admitted to private psychiatric hospitals, voluntarily or by court order, are not subject to this review. Delays in the processing of background checks has become problematic due to an increasing volume of applications and complaints received regarding delays in the processing of these requests
Analyze: Data collected for the 3Q2018 showed that we received 3381 applications, which is 726 less than last quarter.
Improve:The process has been streamlined as we have been working with the state police by eliminating the mailing of the applications from them to RPC and DDPC. RPC has reactivated the medical records email to receive lists of the applicants from the state police that include the DOB and any alias they may have had. This has cut down on paper as well as time taken sorting all the applications. OIT has also created a new patient index in which we are in the process of consolidating sources we search into this one system. Over time this will decrease time spent searching as we will no longer have to search several sources. This is ongoing.
Note: In July 2015, a new State of Maine law was approved effective October 2015. This law no longer requires citizens to have a concealed carry permit to carry a concealed weapon within the State of Maine. However, if citizens want to carry concealed outside Maine they will still need to apply for a concealed carry permit. We expect this to decrease the number of concealed carry permit applications we receive and process.
FY2018Month Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun TotalApplications Received 846 1268 936 1189 712 752 1056 953 1372 9084
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Housekeeping
Responsible Party: Debora Proctor, Housekeeping Supervisor
I. Measure Name: Patient Living AreaThe Housekeeping Department will maintain an acceptable standard of cleanliness and sanitation in patient living areas.
Measure Description: The Housekeeping Supervisor or designee will perform a monthly inspection of the patient living area and record the findings on the Housekeeping Inspection Form. Any unit not meeting the threshold will be inspected every two weeks until compliance is met
Method of Monitoring: Inspection scores will be summarized monthly. Patient areas that fail to meet the threshold will be reported to the IPEC group, EOC, and the Director of Support Services. This report will include any actions taken.
Results:
Unit Target 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Lower Saco
95%
84% 90% 90% 88%Upper Saco 86% 95% 95% 92%Lower Kennebec 86% 91% 91% 89%Upper Kennebec 84% 95% 92% 90%Overall Average 85% 93% 92% 90%
Data Analysis: The Housekeeping Supervisor inspected units monthly. 3Q2018 resulted is 92% which is a 1% decrease from last quarter and within 3% of target. Fiscal year results are within 5% of the target.
Action Plan: The Housekeeping Supervisor will continue to do monthly inspections to assure that cleanliness of the environment continues to improve.
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Human Resources
Person Responsible: Aimee Rice, Human Resources Manager
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I. Measure Name: License Reviews
Measure Description: Ensuring that licenses/registry entries are verified via the appropriate source prior to hire for all licensed (or potentially licensed) new hires.
Type of Measure: Quality Assurance
ResultsUnit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Target PercentageLicenses
Reviewed
FY201498%
100% 100% 100% 100% 100%
Actual100%16/16
100%14/14
100%16/16
100%46/46
Data Analysis: During 3Q2018, there were 19 new hires. Of those, 16 were licensed or potentially licensed. License verification was completed on all 16 employees with potential licenses.
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Infection Control
Person Responsible: Donna Bradeen, RN, Infection Control Nurse
I. Measure Name: Employee Hand Hygiene Rate
Measure Description: Staff will observe the hand hygiene practice of nurses as they pass medications. (10
observations per month) Staff will do 10 hand hygiene observations per month (before & after patient contact)
in the milieu on the 7AM-7PM shift. Staff will do 10 hand hygiene observations per month (before & after patient contact)
in the milieu on the 7PM-7AM shift
Measure Type: Performance Improvement
ResultsUnit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
TargetEmployee
Hand Hygiene Compliance
FY201669% >95% >95% >95% >95% >95%
93% 100% 92% 95%
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Actual
Data:Upper Saco January: 100% Upper Kennebec January: 100%Upper Saco February: 100% Upper Kennebec February: 100%Upper Saco March: 100% Upper Kennebec March: 100%
Lower Kennebec January: 100% Lower Saco January: 100%Lower Kennebec February: 100% Lower Saco February: 100%Lower Kennebec March: 0% Lower Saco March: 100%
Plan: Continue to monitor and measure. A Hand Hygiene Blitz will be planned to increase staff awareness and provide continued education.
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II. Measure Name: Assisting Patients with Daily Hygiene
Measure Description: Staff offer hand gel to patients prior to breakfast, lunch, and dinner, ten (10) days per month.
Measure Type: Quality Assurance
ResultsUnit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Target EmployeeHand
Hygiene Compliance
FY201688%
>95% >95% >95% >95% >95%
Actual 98% 97% 64%* 86%
Data:January 2018: 92%February 2018: 50%March 2018: 50%
Plan: Continue to monitor and measure. *Attempting to use a new method of observation, information was not reported regularly. We will return to the original method of observation.
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Medical Staff
Responsible Party: Dr. Benjamin Grasso, MD
I. Measure Name: Treatment Plans
Measure Description: Treatment plans will be individualized and provider led, patient focused plans for recovery. Short and long-term goals will be individualized and attainable and will relate to the patient’s diagnoses. Interventions will relate to the goals and the diagnoses.
Measure Type: Quality Assurance
Unit Date Patient Focused
Individualized Measurable Short-Term
Goal
Measurable Long-Term
Goal
Interventions relate to goals and Diagnoses
Strengths Utilized in
Interventions
LK January Yes Yes Yes No No NoLK January Yes Yes Yes Yes Yes YesUK January Yes Yes Yes Yes Yes YesUK January Yes Yes Yes Yes Yes YesLS January Yes Yes Yes Yes Yes YesLS January Yes Yes Yes Yes Yes YesUS January Yes Yes Yes No Yes NoUS January Yes Yes Yes Yes Yes NoLK March Yes Yes Yes Yes Yes NoLK March Yes Yes Yes Yes Yes YesUK March Yes Yes Yes Yes Yes NoUK March Yes Yes Yes Yes Yes YesLS March Yes Yes Yes Yes Yes YesLS March Yes Yes Yes Yes Yes NoUS March Yes Yes Yes Yes Yes Yes/NoUS March Yes Yes Yes Yes Yes No
Data Analysis: Starting December 2017, treatment plans are being audited monthly by the Clinical Director. Two plans from each unit for a total of eight will be reviewed each month. The following elements are being recorded: patient focused, individualized, measurable short and long-term goals, interventions related to goals, and diagnoses and strengths utilized in interventions.
January’s data reveals 25% of Long Term Goals were not measurable, 13% of interventions were not relatable to patient’s diagnosis and goals, and 38% did not have patient’s strengths utilized in Providers interventions. March’s data reveals 63% did not have patient’s strengths utilized in Providers interventions. There was no data collected in February due to losing our Clinical Director.
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II. Measure Name: Peer Review
Measure Description: Peer Reviews will be conducted throughout the year by the entire Medical Staff. Each Medical Staff member will receive a copy of their results for their review and signature.
Measure Type: Performance Improvement
Data Analysis: Internal Peer Reviews have been done to 100% compliance of the Medical Staff Bylaws. The format of review has been updated and will be implemented in the 4th Quarter. The new format is more robust and captures the Clinical Judgement of the Provider across the entire span of patient’s care. Due to the lengthy overhaul of the format, there is no 3rd Quarter Internal Peer Review data to be reported on but there will be for the 4th Quarter. An External Peer Review of 67 Psychiatric notes and 18 Internal Medicine notes was completed in October 2017. The overall findings report from the External Peer Review is on file, on premises.
III. Measure Name: Timeliness of Patient History & Physical
Measure Description: Patient’s History & Physical (H&P) shall be done in a timely manner. They will be completed and signed within 24 hours. Should patient refuse their H&P, documentation in Meditech must be entered under an H&P note within 24 hours of refusal. If no H&P is completed, there must be three documented refusals in Meditech.
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Measure Type: Performance ImprovementData Analysis: This is a new measure that was first implemented this 3Q2018. Out of the 65 patient H&Ps spanning the third quarter, there were 11 not completed within the 24-hour requirement equaling 17% of patient H&Ps that were not compliant. Of the 11, 3 were 1 day past due, 5 were 3 days past due, 1 was 4 days past due, 1 was 5 days past due, and 1 was 13 days past due.
IV. Measure Name: AIMS Testing
Measure Description: Patients who are prescribed a regularly scheduled first generation antipsychotic medication will receive an AIMS test at least every 12 months. The charts will be monitored for its completion. Effective April 1, 2018, the Medical Executive Committee changed the rate to every 6 months which will begin in 4Q2018.
Measure Type: Quality Assurance
AIMS TESTING3Q2018
UNIT DATE TESTED
DATE TESTED
DATE TESTED
DATE TESTED
DATE TESTED
DATE TESTED
DATE TESTED
LKSCU 2/22/18 LKSCU 11/8/17 1/30/18
LK 1/18/18 UK 10/30/17 1/31/18
UK Not completed
UK 2/20/18 UK 2/7/18 LS 1/2/18 LS 10/3/17 1/31/18 US 10/11/17 1/22/18 US 7/14/15 1/18/16 7/20/16 1/25/17 US 6/16/16 7/20/16 1/25/17 8/1/17 1/30/18 US 5/31/14 2/4/15 7/15/15 1/18/16 7/20/16 7/31/17 1/22/18US 5/5/17 9/18/17 1/22/18 US 8/9/17 1/22/18 US 8/19/15 1/8/16 7/20/16 1/5/17 7/24/17 1/31/18 US 3/27/18 US 3/11/18 7/18/16 1/30/17 8/1/17 2/6/18
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Not Completed within 6 months
Data Analysis: This is a new measure implemented this 3Q2018. Medical Staff/Pharmacy measures:
V. Measure Name: Polyantipsychotic Therapy
Measure Description: The use of two or more antipsychotic medications (polyantipsychotic therapy) is discouraged as current evidence suggests little to no added benefit with an increase in adverse effects when more than one antipsychotic is used.
The Joint Commission Core (TJC) Measure HBIPS-5 requires that justification be provided when more than one antipsychotic is used. Three appropriate justifications are recognized: 1) Failure of three adequate monotherapy trials, 2) Plan to taper to monotherapy (cross taper) and 3) Augmentation of clozapine therapy. This measure aligns itself with the HBIPS-5 core measure and requires the attending psychiatrist to provide justification for using more than one antipsychotic.
In addition to the justification, the clinical/pharmacological appropriateness is also evaluated.
Type of Measure: Performance Improvement
% of Census 1Q2018 2Q2018 3Q2018 4Q2018 YTDOn 1 Antipsychotic 65 68 67 67%On 2 Antipsychotics 22 18 19 20%On 3 Antipsychotics 1 1 1 1% & of Justification Type 1Q2018 2Q2018 3Q2018 4Q2018 YTDFailed 3 of > 47 25 31 34%Tapering to Monotherapy 41 60 52 51%Clozapine Augmentation 11 13 15 13% % of Patients Discharged 1Q2018 2Q2018 3Q2018 4Q2018 YTDWith Appropriate Justification 100 100 100 100%Without Appropriate Justification 0 0 0 0
Data Analysis: All medication profiles in the hospital are reviewed on admission and in each month of the quarter for antipsychotic medication orders. Attending psychiatrists are required to complete a Polyantipsychotic Therapy Justification Form when a patient is prescribed more than one antipsychotic.
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Action Plan: Continue to monitor and alert prescribers to provide appropriate justification for polyantipsychotic therapy.
VI. Measure Name: Metabolic Monitoring
Measure Description: Metabolic syndrome is a known side effect of second generation/atypical antipsychotics (SGAs). Most patients prescribed antipsychotics are prescribed an entity from the SGA sub-class. The purpose of this monitor is to ensure that we are monitoring therapy appropriately for those patients prescribed SGAs.
Type of Measure: Performance Improvement
ResultsUnit Baseline 1Q2108 2Q2018 3Q2018 4Q2018
Target Complete/Up-to-date
Metabolic Parameters
FY201743%
75% 75% 75% 75%
Actual 73% 74% 83%
Data Analysis: The pharmacy collects data around specified parameters to monitor the metabolic status of all patients in the hospital who are receiving atypical antipsychotics during the quarter. Data elements collected are BMI (body mass index), blood pressure, fasting blood glucose, hemoglobin A1c, HDL cholesterol, and triglycerides.
1Q2018 2Q2018 3Q2018 4Q2018# of Patients on SGA 55 81 82 # of Patients with Complete/Up-to-date Parameters 40 60 68 # of Patients Incomplete/outdated Parameters 15 21 14 # of Patients Meeting Criteria for Metabolic Syndrome 16 24 32 # of Patients without Metabolic Syndrome 24 36 36 # Unable to Determine 15 32 25
Action Plan: We will monitor the stated parameters for metabolic syndrome in patients prescribed second generation/atypical antipsychotic therapy. The patient’s right to refuse assessment (weight, blood pressure and lab work) has been identified as a contributing factor to not being able to fully assess metabolic status. We will continue to work with the medical staff to identify patients whose metabolic profiles are incomplete/inconclusive, in order that we may more accurately monitor the population for
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the hallmark parameters. Patients who have exercised their right to refuse lab draws and/or monitoring are excluded from these calculations.
In patients receiving antihypertensive medications, we conclude that the patient’s untreated blood pressure is greater than 130/85. In patients receiving insulin or oral/injectable antihyperglycemics, we conclude that the patient’s fasting blood glucose >110. In patients receiving statins or other cholesterol-modifying therapy we conclude dyslipidemia.
Comments: Of the 32 patients who met the criteria for Metabolic Syndrome, eight were new admissions in the quarter and 24 were continuing patients with varying lengths of hospitalization. Of those patients admitted in the quarter who met the criteria upon admission, six are readmissions with multiple prior hospitalizations.
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Nursing
Responsible Party: Renee Pfingst, RN, Director of Nursing
I. Measure Name: Mandate Occurrences
Definition: When no volunteers are found 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.
Type of Measure: Performance Improvement
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 occurrences. This process will foster safety in culture and actions by improving communication, improving staffing capacity, mitigating risk factors, supporting the engagement and empowerment of staff. It will also enhance fiscal accountability by promoting accountability and employing efficiency in operations.
Methods of monitoring: Monitoring would be performed by: Staffing Office Database Tracking System Human Resources Department Payroll System
Methods of reporting: Reporting would occur by one or all of the following methods: Staffing Improvement Task Force Nursing Leadership Riverview Nursing Staff Communication
Unit: Mandate shift occurrences
Baseline: September 2013: Nurse Mandates 14 shifts, Mental Health Worker Mandates 49 shifts
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Mandate Occurrences: When no volunteers are found to cover a required staffing need, an employee is mandated to cover the staffing need according to policy.
Base
line
Sept
201
3
1Q2018 2Q2018 3Q2018 4Q2018
Goal
July
201
7
Aug
2017
Sept
201
7
Oct
201
7
Nov
201
7
Dec 2
017
Jan
2018
Feb
2018
Mar
201
8
Apr 2
018
May
201
8
June
201
8
Nursing Mandates 14 0 8 0 3 0 0 0 0 0 0
Mental Health Worker (MHW) Mandates
49 0 1 0 0 1 0 1 0 3 0
Nursing mandates decreased from three last quarter to zero this quarter. MHW mandates increased to from one last quarter to four this quarter.
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II. Measure Name: 3Q2018 Nursing Department Chart Review Effectiveness
Lower Saco
Indicators Findings Compliance
1. Encounter note written between the hours of 0700-2300. 15/15 100%
2. Encounter note written by mental health worker/acuity specialists between the hours of 0700-2300. 14/15 93%
3. A shift assessment is completed each shift. 9/15 60%
4. Weekly Summary note completed. 12/151 N/A 87%
5. Observational note completed on patient who is on a higher level of observation i.e. ¼ hour checks or 1:1.
14/151 N/A 100%
6. Annual nursing assessment completed. 15 N/A 100%
7. Patient’s Rights reviewed and signed. 11/154 LOC 100%
8. Informed Consent signed, dated and timed. 10/155 LOC 100%
9. Number of Telephone Orders for the month. 58/58 100%
10. Number of Telephone Orders signed by the prescriber within 24 hours. 58/58 100%
11. Percentage of patient mall attendance for the month. - -
12. Is the patient prescribed 10 core groups? 9/151 unable
3 N/A87%
13. Is the patient maintaining 75% of core group attendance? 6/151 unable
5 N/A80%
14. Were patient’s levels changed if less than 75% attendance in core groups?
4/151 unable
8 N/A87%
15. MHW/AS attendance at all treatment team meetings? 15/15 100%
16. Attendance of on unit groups for patients too sick to go to the mall. 10/154 N/A 93%
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17. Treatment plan reviewed/modified every 2 weeks. 13/152 N/A 100%
18. Suicide risk assessment reviewed/modified every 2 weeks during the treatment team meeting. 15/15 100%
19. Fall risk assessment reviewed/modified every 2 weeks during the treatment team meeting 15/15 100%
20. Medical Treatment Plans updated every 2 weeks during the treatment team meeting. 15/15 100%
LOC = Lack of capacity Ref = Refusal to sign
Upper Saco
Indicators Findings Compliance
1. Encounter note written between the hours of 0700-2300. 12/15 80%
2. Encounter note written by mental health worker/acuity specialists between the hours of 0700-2300. 13/15 87%
3. A shift assessment is completed each shift. 11/15 73%
4. Weekly Summary note completed. 15/15 100%
5. Observational note completed on patient who is on a higher level of observation i.e. ¼ hour checks or 1:1.
11/153 N/A 93%
6. Annual nursing assessment completed. 8/157 N/A 100%
7. Patient’s Rights reviewed and signed. 15/15 100%
8. Informed Consent signed, dated and timed. 15/15 100%
9. Number of Telephone Orders for the month. 23/23 100%
10. Number of Telephone Orders signed by the prescriber within 24 hours. 21/23 91%
11. Percentage of patient mall attendance for the month. - -
12. Is the patient prescribed 10 core groups? 13/152 N/A 100%
13. Is the patient maintaining 75% of core group attendance? 8/154 N/A 80%
14. Were patient’s levels changed if less than 75% attendance in core 9/15 100%
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groups? 6 N/A
15. MHW/AS attendance at all treatment team meetings? 13/151 N/A 93%
16. Attendance of on unit groups for patients too sick to go to the mall. 2/1510 N/A1 Ref
87%
17. Treatment plan reviewed/modified every 2 weeks. 14/151 N/A 100%
18. Suicide risk assessment reviewed/modified every 2 weeks during the treatment team meeting.
2/1513 N/A 100%
19. Fall risk assessment reviewed/modified every 2 weeks during the treatment team meeting
14/151 N/A 100%
20. Medical Treatment Plans updated every 2 weeks during the treatment team meeting. 15/15 100%
LOC = Lack of capacity Ref = Refusal to sign
Lower Kennebec
Indicators Findings Compliance
1. Encounter note written between the hours of 0700-2300. 15/15 100%
2. Encounter note written by mental health worker/acuity specialists between the hours of 0700-2300. 15/15 100%
3. A shift assessment is completed each shift. 15/15 100%
4. Weekly Summary note completed. 15/15 100%
5. Observational note completed on patient who is on a higher level of observation i.e. ¼ hour checks or 1:1.
9/156 N/A
100%
6. Annual nursing assessment completed. 15 N/A 100%
7. Patient’s Rights reviewed and signed. 15/15 100%
8. Informed Consent signed, dated and timed. 14/151 Loc
100%
9. Number of Telephone Orders for the month. 33/33 100%
10. Number of Telephone Orders signed by the prescriber within 24 33/33 100%
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hours.
11. Percentage of patient mall attendance for the month. - -
12. Is the patient prescribed 10 core groups? 13/15 87%
13. Is the patient maintaining 75% of core group attendance? 6/151 N/A 47%
14. Were patient’s levels changed if less than 75% attendance in core groups?
4/1511 N/A 100%
15. MHW/AS attendance at all treatment team meetings? 8/15 53%
16. Attendance of on unit groups for patients too sick to go to the mall. 3/1510 N/A 87%
17. Treatment plan reviewed/modified every 2 weeks. 15/15 100%
18. Suicide risk assessment reviewed/modified every 2 weeks during the treatment team meeting. 15 N/A 100%
19. Fall risk assessment reviewed/modified every 2 weeks during the treatment team meeting 15/15 100%
20. Medical Treatment Plans updated every 2 weeks during the treatment team meeting. 15/15 100%
LOC = Lack of capacity Ref = Refusal to sign
Upper Kennebec
Indicators Findings Compliance
1. Encounter note written between the hours of 0700-2300. 13/15 87%
2. Encounter note written by mental health worker/acuity specialists between the hours of 0700-2300. 11/15 73%
3. A shift assessment is completed each shift. 15/15 100%
4. Weekly Summary note completed. 15/15 100%
5. Observational note completed on patient who is on a higher level of observation i.e. ¼ hour checks or 1:1.
5/1510 N/A 100%
6. Annual nursing assessment completed. 15/15 100%
7. Patient’s Rights reviewed and signed. 15/15 100%
8. Informed Consent signed, dated and timed. 15/15 100%
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9. Number of Telephone Orders for the month. 14/14 100%
10. Number of Telephone Orders signed by prescriber within 24 hours. 14/14 100%
11. Percentage of patient mall attendance for the month. - -
12. Is the patient prescribed 10 core groups? 11/15 73%
13. Is the patient maintaining 75% of core group attendance? 12/15 80%
14. Were patient’s levels changed if less than 75% attendance in core groups?
1/1510 N/A 73%
15. MHW/AS attendance at all treatment team meetings? 15/15 100%
16. Attendance of on unit groups for patients too sick to go to the mall. 7/155 N/A1 Ref
87%
17. Treatment plan reviewed/modified every 2 weeks. 14/15 93%
18. Suicide risk assessment reviewed/modified every 2 weeks during the treatment team meeting. 14/15 93%
19. Fall risk assessment reviewed/modified every 2 weeks during the treatment team meeting 15/15 100%
20. Medical Treatment Plans updated every 2 weeks during the treatment team meeting. 15/15 100%
LOC = Lack of capacity Ref = Refusal to sign
Total - All Units
Indicators Findings Compliance
1. Encounter note written between the hours of 0700-2300. 55/60 92%
2. Encounter note written by mental health worker/acuity specialists between the hours of 0700-2300. 53/60 88%
3. A shift assessment is completed each shift. 50/60 83%
4. Weekly Summary note completed. 57/601 N/A 97%
5. Observational note completed on patient who is on a higher level of observation i.e. ¼ hour checks or 1:1.
39/6020 N/A 98%
6. Annual nursing assessment completed. 23/6037 N/A 100%
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7. Patient’s Rights reviewed and signed. 56/604 LOC 100%
8. Informed Consent signed, dated and timed. 54/606 LOC 100%
9. Number of Telephone Orders for the month. 128/128 100%
10. Number of Telephone Orders signed by the prescriber within 24 hours. 126/128 98%
11. Percentage of patient mall attendance for the month. - -
12. Is the patient prescribed 10 core groups? 46/601 unable
5 N/A87%
13. Is the patient maintaining 75% of core group attendance? 32/601 unable10 N/A
72%
14. Were patient’s levels changed if less than 75% attendance in core groups?
18/601 unable35 N/A
73%
15. MHW/AS attendance at all treatment team meetings? 51/601 N/A 87%
16. Attendance of on unit groups for patients too sick to go to the mall. 22/6029 N/A2 Ref
90%
17. Treatment plan reviewed/modified every 2 weeks. 56/603 N/A 98%
18. Suicide risk assessment reviewed/modified every 2 weeks during the treatment team meeting.
31/6018 N/A 82%
19. Fall risk assessment reviewed/modified every 2 weeks during the treatment team meeting
59/601 N/A 100%
20. Medical Treatment Plans updated every 2 weeks during the treatment team meeting. 60/60 100%
LOC = Lack of capacity Ref = Refusal to sign
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Peer Support
Responsible Party: Julia Duncan, Peer Support Coordinator
I. Measure Name: Inpatient Consumer Survey Return RateMeasure Description: 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.
Those 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 check-ins
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 Target 1Q2018 2Q2018 3Q2018 4Q2018 YTD
The inpatient consumer survey is the primary tool for collecting data on how patients feel about the services they are provided at the
LK 50% 33%4/12
43%6/14
60%9/15
46%19/41
LS 50% 50%5/10
27%3/11
59%10/17
47%18/38
UK 50% 84%21/25
71%17/24
56%14/25
70%52/74
US 50% 100%3/3
80%8/10
1007/7
90%18/20
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hospital. Overall 50% 66%33/50
58%34/59
63%40/64
62%107/173
Comments: Percentages are calculated based on the number of people eligible to receive a survey vs. the number of people who completed the surveys. Peer Support has exceeded 50% baseline for two consecutive quarters.
Inpatient Consumer Survey Results:
# Indicators1Q
20182Q
20183Q
20184Q
2018YTD
Average1 I am better able to deal with crisis. 60% 57% 62% 60%2 My symptoms are not bothering me as much. 60% 60% 63% 61%3 The medications I am taking help me control
symptoms that used to bother me. 61% 61% 61% 61%
4 I do better in social situations. 61% 62% 62% 62%5 I deal more effectively with daily problems. 63% 58% 64% 62%6 I was treated with dignity and respect. 64% 58% 63% 62%7 Staff here believed that I could grow, change and
recover. 63% 69% 63% 65%
8 I felt comfortable asking questions about my treatment and medications. 66% 63% 60% 63%
9 I was encouraged to use self-help/support groups. 67% 68% 62% 66%10 I was given information about how to manage my
medication side effects. 63% 63% 61% 62%
11 My other medical conditions were treated. 64% 65% 62% 64%12 I felt this hospital stay was necessary. 61% 50% 63% 58%13 I felt free to complain without fear of retaliation. 63% 55% 63% 60%14 I felt safe to refuse medication or treatment
during my hospital stay. 61% 49% 64% 58%
15 My complaints and grievances were addressed. 61% 63% 64% 63%16 I participated in planning my discharge. 63% 66% 64% 64%17 Both I and my doctor or therapist from the
community were actively involved in my hospital treatment plan.
63% 59% 62%61%
18 I had an opportunity to talk with my doctor or therapist from the community prior to discharge. 61% 57% 62% 60%
19 The surroundings and atmosphere at the hospital helped me get better. 61% 58% 62% 60%
20 I felt I had enough privacy in the hospital. 61% 62% 62% 61%21 I felt safe while I was in the hospital. 63% 64% 63% 63%22 The hospital environment was clean and 63% 63% 63% 63%
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comfortable.23 Staff were sensitive to my cultural background. 61% 65% 62% 62%24 My family and/or friends were able to visit me. 63% 70% 63% 65%25 I had a choice of treatment options. 62% 61% 64% 62%26 My contact with my doctor was helpful. 62% 63% 63% 64%27 My contact with nurses and therapists was helpful. 61% 66% 64% 64%28 If I had a choice of hospitals, I would still choose
this one. 63% 63% 64% 63%
29 Did anyone tell you about your rights? 63% 66% 65% 65%30 Are you told ahead of time of changes in your
privileges, appointments, or daily routine? 65% 65% 65% 65%
31 Do you know someone who can help you get what you want or stand up for your rights? 65% 66% 65% 65%
32 My pain was managed. 65% 66% 66% 66%Overall Score 62% 62% 65% 63%
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Pharmacy Services
Responsible Party: Michael Migliore, Director of Pharmacy
I. Measure Name: Controlled Substance Loss Data
Measure Description: Daily and monthly comparison of Pyxis vs CII Safe Transaction Report.
Type of Measure: Quality Assurance
Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD Average
TargetFY2017
11/month
0 0 0 0 0# of
Discrepancies 16/month 19/month 26/month 20/month
Number of CS lost 0 1 0 0 0
Data Analysis: The average number of controlled substance discrepancies per month for the 3Q2018 was 26. This figure represents the number of discrepancies that occurred and not the number of controlled substances lost. Discrepancies typically occur from miscounts which are all investigated and reconciled.
Action Plan: Continue to remain vigilant and to educate staff on proper automated dispensing cabinet procedures to avoid the creation of discrepancies.
Comments: The Pharmacy department will continue to monitor, track, and trend inconsistencies.
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II. Measure Name: Invalid Orders
Measure Description: Incomplete/Invalid Orders.
Type of Measure: Performance Improvement
Background: With a zero-tolerance policy for invalid orders, every prescribed order must contain the drug name, strength, administration route, dosing frequency, provider signature, order time and date, accurate allergy and adverse drug reaction information, and indication. Receiving an invalid order by the pharmacist requires documentation, copying and returning the invalid order to the prescriber for remediation as well as contacting and informing the unit of the invalid order.
Data Analysis: For the 3Q2018, the numbers of invalid orders are higher than the previous quarters. January reported 18, February 11, and March 30. The total number of invalid/incomplete orders were 59 for the 3Q2018. The chart below represents the breakdown of the quarterly metrics. Possible cause for the increase in this metric for this quarter is the arrival of new providers.
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January February March TOTALAllergy/ADRDate/time 3 4 6 13Frequency 1 1Indication 10 4 11 252 Pt. Identifiers 1 1 2Route 1 2 2 5Signature 2 1 7 10Strength 3 3OtherTOTAL 18 11 30 59
This metric is reported at the monthly Pharmacy and Therapeutics Committee meeting to keep the medical staff informed of the findings. The Pharmacy department has taken additional time during provider orientation to stress the importance of this patient safety issue.
Action Plan: Tracking incomplete orders will continue until the implementation of electronic health records scheduled to be implemented in the upcoming year. The system will contain hard stops preventing providers to proceed to initiate an order that is not complete.
III. Measure Name: Veriform Medication Room Audits
Measure Description: Comprehensive Unit Compliance Audits
Type of Measure: Quality Assurance
ResultsUnit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Target
All FY2016100%
100% 100% 100% 100% 100%
Actual 100% 100% 100% 100%
Data Analysis: The medication room audits have been concluded for the 3Q2018 without completion deficiencies.
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Audit Compliance Findings: The Pharmacy Medication Room Audits for all the units have been completed for the 3Q2018.Action Plan: No deficiencies were noted with pharmacy’s completion of the medication room audits. Pharmacy staff will continue to operate to maintain 100% completion and will continue reporting any noted deficiencies to Nursing staff and administration if necessary.
Comments: Continuous monitoring of the medication room audits and approval by the responsible individuals has again provided satisfactory results for this quarter.
IV. Measure Name: Fiscal Accountability
Measure Description: Monthly Tracking of Dispensed Discharge Prescriptions
Type of Measure: Quality Assurance
Results Unit Baseline/Qtr. 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Actual AllFY2018$5096
For 284 Rx’s
$3942for 249
Rx’s
$3874For 248
Rx’s
$6301For 372
Rx’s
$14,117for 869
Rx’s
Data Analysis: Riverview Psychiatric Center’s Extended Hospital Pharmacy license permits it to dispense medication to both inpatients and outpatients. Most of the outpatient prescriptions are for a 7-day supply of discharge medications. Administrative approval is required when a greater than 7-day supply is needed. Discharge prescriptions serve to cover the patient’s needs until they can obtain medications in the community.
Action Plan: To provide comprehensive medication adherence, the Pharmacy Department will continue to monitor and track outpatient prescriptions and provide medications to discharge patients that are covered on their outpatient insurance formulary when applicable.
BaselineAvg. Qtr. FY2017
1Q2018 2Q2018 3Q2018 4Q2018 YTD
$ spent $5096 $3942 $3874 $6301 $14,117# RX’s 284 249 248 372 869
$ per Rx $17.95 $15.83 $15.61 $16.94 $16.95
Comments: The 3Q2018 reported a significant increase in the number of discharge Rx’s as compared to the 2Q2018. The cost of a third quarter prescription was $16.94, a $1.33 increase from 2Q2018 and a
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$1.01 decrease from baseline. Whenever possible, the Pharmacy department dispenses per the formulary. In specific instances, with approval from the Pharmacy department, the dispensing of non-formulary pharmaceuticals is utilized to assist our patients.V. Measure Name: Dispensing Process
Measure UnitBaseline
2017 Goal1Q
20182Q
20183Q
20184Q
20181. Controlled Substance Loss Data: Daily Pyxis-CII Safe Compare Report.
All0
0Target:Actual:
01
00
00
2. Controlled Substance Loss Data: Monthly CII Safe Vendor Receipt Report.
Rx0
0Target: 0Actual: 0
00
00
00
3. Controlled Substance Loss Data: Monthly Pyxis Controlled Drug Discrepancies.
All 0/mo Target: 0
Actual: 00
4716/mo
057
19/mo
079
26/mo4. Medication Management Monitoring: Measures of drug reactions, adverse drug events, and other management data.
Rx5/year Target: 0
Actual: 003
01
00
5. Medication Management Monitoring: Resource Documentation Reports of Clinical Interventions.
Rx244/
quarter
100%Target:Actual:
100%67
100%269
100%264
6. Psychiatric Emergency Process: Monthly audit of all psych emergency measures against eight criteria.
All 100% 100%Target:Actual:
100%100%
100%100%
100%100%
7. Operational Audit:Monthly audit of three operational indicators from CPS contract.
Rx 100% 100%Target:Actual:
100%100%
100%100%
100%100%
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Psychology
Responsible Party: Arthur DiRocco, Ph.D.
I. Measure Name: Psychology Progress Notes
Measure Description: This was a new performance improvement initiative. Psychology progress notes were accessed through the Meditech data collection system to ascertain that the notes being entered in a patient’s chart reflect the contributions to treatment being done with patients. It was not possible to evaluate all electronic entries made over the year to determine totals for each psychologist working with clients. A random sample of 33 patients from RPC were selected to determine the number of entries made for each over an average of one year. The number of progress notes entered into the medical record for all 33 patients was approximately 2,726 per year. The average number of data entries per patient was 84. The following scatter plot shows distribution of electronic notes (PCS and EMR) submitted by psychology department over the period of 2014 thru 2018. Type of Measure: Performance improvement
Data Analysis: The most salient finding of this initiative was the sheer quantity of data that has been compiled in the electronic record. Information contributed by members of the psychology department that is routinely entered includes individual reports, assessments, behavior plans, test data, small group and individual treatment efforts. Accessing this data for important information and guidance is a time-consuming enterprise. The quality of most reports and assessments is considered adequate and contributory to good medical care. The total number of electronic items entered by psychologists in the
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3Q FY2018 was 962 entries. This is a quarterly average of 87.5 entries (standard deviation 48) per patient. One of the short-comings of the current data base is the inability to search for information that can be of benefit to the treatment team and in turn to the individual patient. The ability to track patient progress and behavioral indexes through a computer data search would be of great value in the treatment of patients.
II. Measure Name: Intake Assessment Completion Rates
Measure Description: All patients entering RPC for treatment are evaluated by the psychology department to provide a brief but accurate assessment of basic neuro-psychological functioning. The results of this brief evaluation are provided to the treatment team for their consideration of the patient’s treatment needs while at RPC. The goal of the psychology department is to provide the treatment team with a brief intake assessment for 100% of the patients entering the hospital within seven days of their arrival.
Type of Measure: Performance improvement
Data Analysis: This initiative is part of a hospital wide effort to improve the delivery of mental health services to all patients. The chart on the following shows the changes in the data being collected and the improvement in goal attainment. Baseline data collection began in the month of July 2017 with only 31% of the assessments being completed. Beginning in August the department identified the need to provide timely and cogent information regarding incoming patients. As the data shows there was a
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considerable increase in completed assessments and the meeting of timelines for delivery of services within 7 days.
Action Plan: The department is making considerable progress in meeting the request for services but will need to maintain close vigilance on the arrival and departure of patients. Another factor hindering higher outcomes is the inability or unwillingness of patient participation in the assessment process which has accounted for up to 3 refusals per month. The overall rate of improvement over the last 3 quarters is 75%. 98% of the assessments completed by the department psychologists are within the 7-day time frame.
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Rehabilitation Services(Occupational Therapy, Therapeutic Recreation, Vocational Services,
Chaplaincy, Patient Education)
Responsible Party: Janet Barrett, CTRS, Director of Rehabilitation Services
I. Measure Name: Recreational Therapy Assessment
Measure Description: Improving health outcomes/patient care. To receive effective treatment, all patients admitted to RPC will take part in a Recreational Therapy Assessment within seven days of admission. Each Recreation Therapist will then use this assessment to assist in the formulation of treatment interventions to assist patients in returning to a satisfying and meaningful life upon discharge. Target is to achieve and maintain an overall goal of 100% for four consecutive quarters.
Type of Measure: Performance Improvement
Results
Unit Baseline
1Q2018
2Q2018
3Q2018
4Q2018 YTD
Target Percent of Initial Rec
Assessments within 7
days
90%
100% 100% 100% 100% 100%
Actual 89%47/53
97%57/59
93%56/60
93%160/17
2
Data Analysis: Of the 60 admissions during this quarter, four of the admissions did not have their initial assessment completed within the 7-day time frame. Two of the late assessments were 1-day past admission, one was a long term forensic patient who was discharged for medical reasons to MGMC and then readmitted, and the RT on the unit was not aware she had to do another assessment. The final late assessment was one that the unit RT missed doing completely, and the patient was discharged.
Action Plan: Meet with the Recreation Therapists and develop a tracking system for admissions to ensure all assessments are completed in the allotted time frame and remind them to reach out to Float RT for assistance, especially when the unit RT is on vacation, as deadline approaches, as well as putting an assessment in the chart within time frame noting patient’s unwillingness to participate in the process.
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Risk Management
Responsible Party: Melanie Crockett, RN, Risk Manager
I. Measure Name: Reporting Allegations of Abuse, Neglect and Exploitation
Riverview Psychiatric Center will report all allegations of abuse, neglect, and exploitation to the required parties with the timeframes specified, not to exceed 24 hours.
Measure Description: Training of new and existing staff for reporting all allegations of abuse, neglect and exploitation has been increased. During New Employee Orientation (NEO) there has been additional time added for the Risk Manager to train staff on accurate and timely reporting. Also during NEO there is a time scheduled for hospital leaders to meet with new employees; the presentation includes the importance of recognizing and reporting allegations of abuse, neglect and exploitation, and maintaining therapeutic boundaries. A total of 48 employees have been hired since April of 2017; 40 employees attended the Leadership/Welcome portion of NEO.
Existing staff have had two opportunities added for increased training on reporting all allegations of abuse, neglect, and exploitation (RANE). Annually there is a competency test that is sent out to the staff for completion. All training records are maintained in the Staff Development office; 375/409 (91%) employees have taken RANE training. During every yearly evaluation, the staff’s supervisor will review the expectations and policy for reporting all allegations of abuse, neglect and exploitation and have the employee sign off on it. All evaluation records are maintained in the Human Resource office. The Risk Manager will maintain a monthly list of all allegations of abuse, neglect, and exploitation. The Risk Manager will audit all incident reports to verify that all of the notifications have been made in a timely manner. If any of the allegations have not been reported, the Risk Manager will report them to the respected parties. The Risk Manager will report all allegations of abuse, neglect, and exploitation monthly to the Court Master, Patient Advocates, and the Human Rights Committee; and quarterly to the Integrated Performance Excellence Committee (IPEC).
Type of Measure: Quality Assurance
1Q2018 2Q2018 3Q2018 4Q2018 YTDTarget 100% 100% 100% 100% 100%Actual 72% 94% 93% 86%
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43/61 50/53 65/70 158/184
Date Analysis: January had a total of 25 reportable events, 1 was reported late; February had a total of 27 reportable events, 2 were reported late; March had a total of 18 reportable events, 2 were reported late.
Action Plan: Risk Manager notifies each staff member and his/her supervisor of the late reporting. Supervisors monitor their staff for accurate completion of incident reports, including notifying
all parties of any allegations of abuse, neglect, and exploitation.
II. Measure Name: Investigating Allegations of Abuse, Neglect, and Exploitation
Measure Description: All allegations of abuse, neglect and exploitation are reviewed each work day in a Morning Administrative Meeting. Risk Manager or designee will assign allegations of abuse, neglect, and exploitation alleged to have happened within RPC or associated entities, and/or involving RPC staff to the appropriate staff for further review. In the instance that these allegations may lead to staff discipline of any kind; the Risk Manager will immediately notify Human Resources and formally hand the allegation(s) over to them for an HR investigation. The Risk Manager, in conjunction with the HR director will maintain a record of all substantiated allegations of abuse, neglect, and exploitations which happened within RPC or associated entities, and /or involving RPC staff.
Type of Measure: Quality Assurance
Results: There were no allegations of abuse, neglect, or exploitation forwarded to HR for follow up.
III. Measure Name: Riverview Psychiatric Center will maintain compliance with regulatory and accreditation findings.
Measure Description: The Risk Manager will audit all areas of deficiencies noted on the 2016 Joint Commission Accreditation Survey for 100% compliance. The Risk Manager will receive information on a monthly basis from all departments responsible for the deficiencies noted on the 2016 Joint Commission Accreditation Survey. The Risk Manager will audit each citation at a minimum of one time quarterly to verify 100% compliance.
Type of Measure: Performance Improvement
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Target is 100%1Q2018 2Q2018 3Q2018 4Q2018 YTD
APR.09.01.01 EP2 TJC Telephone Number posted in the lobby and on the website
100% 100% 100% 100%
CTS.02.01.03 EP1 Initial Assessments
100% 100% 100% 100%
CTS.02.01.03 EP4 Family input gathered for
patient assessment
100% 100% 100% 100%
CTS.03.01.05 EP1, EP2
Family invited to participate in
training
100% 100% 100% 100%
HRM.01.01.01 EP1 All job descriptions
have signatures
100% 100% 100% 100%
EC.02.02.01 EP5 Eye Wash Stations in
place
100% 100% 100% 100%
EC.02.03.03 EP3 Fire Drills adequately
spaced apart
100% 100% 100% 100%
EC.02.03.05 EP3, EP 4, EP9
All equipment is documented
100% 100% 100% 100%
EC.02.04.01 EP4 Equipment Preventative Maintenance
Schedule
100% 100% 100% 100%
EC.02.05.01 EP8 Breaker Panel Labeled
100% 100% 100% 100%
EC.02.06.01 EP1 Piano Hinges on Seclusion door
100% 100% 100% 100%
EC.02.06.05 EP2 Evaluate 100% 100% 100% 100%
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Infection Control during
building construction
HRM.01.01.01 EP1 All job descriptions
have signatures
100% 100% 100% 100%
HRM.01.01.03 EP2 All clinicians licensed in
Maine
100% 100% 100% 100%
HRM.01.02.01 EP1, EP2
Primary Source verification
100% 100% 100% 100%
HRM.01.03.01 EP2 Staff orientation to
specific services
100% 100% 100% 100%
HRM.01.07.01 EP2 Performance Reviews
100% 100% 100% 100%
LS.02.01.10 EP4 Penetrations in doors
100% 10% 10% 100%
LS.02.01.30 EP2 EP11 Penetrations around conduit
sleeves
100% 100% 100% 100%
LS.02.01.34 EP4 Breaker Panel labeled in red
100% 100% 100% 100%
LS.02.01.35 EP5, EP14
Sprinkler Heads are free of
debris
100% 100% 100% 100%
MM.01.01.01 EP1, EP2
EMR 100% 100% 100%
MM.03.01.01 EP2 Refrigerator Logs
100% 100% 100% 100%
NPSG.03.06.01 EP1 Medication Reconciliations
100% 100% 100% 100%
NPSG 15.01.01 EP1 Suicide Screening
100% 100% 100% 100%
PC.01.02.07 EP3 Pain Assessment
100% 100% 100% 100%
PC.02.02.03 EP11 Refrigerator Temp Logs for Patient Food
100% 100% 100% 100%
RC.01.02.01 EP2 MD Co-signatures for
100% 100% 100% 100%
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S/R for PA-CWT.04.01.01 EP4 Glucose
Monitoring100% 100% 100% 100%
IV. Measure Name: All Riverview Psychiatric Center staff will receive training regarding the prompt reporting of all suspected boundary violations.
Measure Description: All employees must take an annual competency training and examination on prompt reporting of allegations of suspected boundary violations.
Type of Measure: Performance Improvement.
Results: Boundaries training has been extended during New Employee Orientation. In addition, Boundaries training is included in RPC’s Annual competencies.
1Q2018 2Q2018 3Q2018 4Q2018 YTDTarget 100% 100% 100% 100% 100%Actual 70%
288/40987%
389/44489%
397/44483%
1074/1297
Data Analysis: Eighty-three percent of staff have completed their new employee and/or annual training to date. All new employees are trained during their initial training period and supervisors are to follow-up with staff that have not completed this module of their annual training.
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Safety & Security
Responsible Party: Philip Tricarico, Safety Officer
I. Measure Name: Contraband/Prohibited Items Incidents
Measure Description: Contraband/prohibited items found during front Lobby screening done by security staff of patients and visitors, to create and foster a safe environment for all staff, patients, and visitors.
“Contraband” is a term used to describe ant items that are illegal to possess/use by statute. RPC knowledge of possession/use of such item(s) on RPC property may involve law enforcement notification/ intervention. Contraband as identified in statute “means any tool or other item that may be used to facilitate of section 755, a dangerous weapon or a scheduled drug as defined in section 1101, subsection 11, unless in the case of a patient at a state hospital. As used in this section, “state hospital” means the Riverview Psychiatric Center. A person is guilty of trafficking in contraband in a state hospital if:
1. That person intentionally conveys or attempts to convey a dangerous weapon to any patient at a state hospital. Violation of this paragraph is a Class C crime.
2. That person intentionally conveys or attempts to convey contraband, other than a dangerous weapon to any patient at a state hospital. Violation of this paragraph is a Class D crime.
3. Being a patient at a state hospital, that person intentionally makes, obtains or possesses contraband Violation of this paragraph is a Class D crime.
“Prohibited” is a term used to describe any items that are not illegal to possess / use. But are not permitted for entry into the secure areas in the RPC building or permitted for possession / use on RPC grounds. Unless specified otherwise by stature or hospital policy. Some prohibited items may be secured in a locked vehicle or at security.
Objective: Through inspection, observation, and aggressive incident management, an effective management process would limit or eliminate the likelihood that a safety/security incident would occur. This process would ultimately create and foster a safe environment for all staff, patients, and visitors.
Those Responsible for Monitoring: Monitoring would be performed by Safety Officer, Security Site-Manager, Security Officers, Operations Supervisor, Operations staff, Director of Support Services, Director of Environmental Services, Environmental Services staff, Supervisors, and frontline staff.
Methods of Monitoring: Direct observation Cameras Front Lobby security screening of patients and visitors.
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Methods of Reporting: Reporting would occur by one or all of the following methods; Daily Activity Reports (DAR’s) Incident Reporting System (IR’s)
Unit: Hospital Wide
Baseline: 5% reduction of contraband/prohibited found each Q
Goal: Baseline: - 5% each Quarter
ResultsBaseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Target1Q2017
3089
1997 2261 - 5%= 2148
2617- 5%= 2487
3184-5%= 3024 2935
Actual 2261 2617 3184 2687
3Q2018: We did not meet our goal for this quarter. Although we are tracking 17 different categories of contraband and prohibited items for this indicator, we are only reporting the items that pose the greatest risk/hazard to the patients and facility. Being a new PI measure, this is a work in progress. We may change some of the items and reporting format to better suite our needs. For instance, keys and cellphones account for a very large share of items held. However, almost every visitor has these two items so Security specifically asks for and looks for them. Therefore, the risk of them getting by Security is very minimal.
Matches and lighters are easy to be missed in a screening. Therefore, they will be reported for this CPI. The same goes for drugs and pens. If any of these items gets past Security, it could have serious consequences for our patients and facility. We are also including known failures, incidents where an item should be held by Security but somehow got through. We are utilizing incident reports to record failures. IR’s eliminate any bias or hearsay information. We had a net increase in the four items we are tracking (weapons, drugs, lighters and Pens/Pencils). The data also points to Wednesday being the busiest day of the week for contraband/prohibited items. This can be explained by the District Court cases heard here. We get a noticeable increase in outside visitors on this day.
Weapons: 4Lighters: 72Drugs (prescription and other): 5Pens/Pencils: 78
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EVENT DATE TIME
LOCATION DISPOSTION COMMENTS
There were no reported Security failures this quarter.
II. Measure Name: Grounds Safety/Security Incidents
Measure Description: Safety/Security incidents occurring on the grounds at Riverview Grounds, being defined as outside the building footprint of the facility, being the secured yards, parking lots, pathways surrounding the footprint, unsecured exterior doors, and lawns. Incidents being defined as: acts of thefts, vandalism, injuries, mischief, contraband found, and safety / security breaches. These incidents shall also include “near misses, being of which if they had gone unnoticed, could have resulted in injury, an accident, or unwanted event”.
Objective: Through inspection, observation, and aggressive incident management, an effective management process would limit or eliminate the likelihood that a safety/security incident would occur. This process would ultimately create and foster a safe environment for all staff, patients, and visitors.
Those Responsible for Monitoring: Monitoring would be performed by Safety Officer, Security Site-Manager, Security Officers, Operations Supervisor, Operations staff, Director of Support Services, Director of Environmental Services, Environmental Services staff, Supervisors, and frontline staff.
Methods of Monitoring: Monitoring would be performed by; Direct observation Cameras Patrol media such as “Vision System” Assigned foot patrol
Methods of Reporting: Reporting would occur by one or all of the following methods: Daily Activity Reports (DAR’s) Incident Reporting System (IR’s) Web-based media such as the Vision System
ResultsBaseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD
Target10
4 1 2 2 9
Actual 1 2 2 5
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The 3Q2018 target was two. We achieved our goal! We have not had any issues this quarter with state owned pickup trucks and the contraband they frequently contained. We have been working with Capitol Police, Fleet Management and the Department of Conservation (agency the trucks are assigned to). There has been significant improvement in how often we are finding dangerous and prohibited items in these trucks.
Our two incidents this quarter involved unlocked cars that staff use to transport patients to appointments, outings etc. We believe the sudden increase in these unlocked vehicles involves the fact that much of the fleet is new to Riverview. We think staff are using the remote and accidently hitting the wrong button, unlocking the car instead of locking it. They are not familiar with the new remotes. To mitigate this issue, we have sent repeated emails to staff reminding them of the importance of locking the vehicle. A signoff was added that Security and staff must acknowledge, verifying that the car is locked. We will continue to monitor this situation.
We are pleased that in all the events, our Security staff or clinical staff had discovered/processed the event before there was a negative impact to the patients. The use of surveillance equipment plays an integral part in combating safety and security threats to people and property. Our aggressive rounds by Securitas continue to prove it is a valuable tool regarding Security’s presence and patrol techniques. Our Security staff, along with its cohesiveness with the Clinical component of the hospital, has proven to be most effective in our management of practices.
Event Date Time Location Disposition Comments
State Vehicle Left Unlocked
2/5/18 1625 Front Parking Lot
Vehicle Locked and Secured
State vehicles have a credit card and other items that should be locked for safety.
State Vehicle Left Unlocked
2/20/18 2254 Front Parking Lot
Vehicle Locked and Secured
State vehicles have a credit card and other items that should be locked for safety.
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Staff Education
Responsible Party: Susan Bundy, Director of Staff Development
I. Measure Name: Ongoing Education and Training
Measure Description: HR.01.05.03 requires that staff will participate in ongoingeducation and training to increase and maintain their competency.
Type of Measure: Performance Improvement
Goal: 90% of direct support staff will attend Collaborative Pro Active Solutions training by June 2018. Attendance will be tracked by Staffing and Organizational Development. Progress will be reported quarterly.
Progress: Collaborative Pro Active Solutions (CPS) has been provided at RPC since November 2016. Since that time 135 staff have received training. In addition, we have been providing CPS training to staff on the Lower Saco and Lower Kennebec unit weekly since February 2018. 26 staff have attended at least one session every other week on the Lower Saco unit. 28 staff have attended at one or more sessions every other week on the Lower Kennebec unit.
II. Measure Name: Seclusion and Restraint Reduction
Measure Description: Because restraint and seclusion have the potential to produce serious consequences, such as physical and psychological harm, loss of dignity, violation of the rights of an individual served, and even death, organizations continually explore ways to prevent, reduce, and strive to eliminate restraint and seclusion through effective performance improvement initiatives.
Type of Measure: Performance Improvement
Goal: RPC will decrease the use of seclusion and restraint by 50%.
FY2018 Manual Holds Mechanical Restraints
Locked Seclusion Total events per quarter
1Q2018 46 0 20 662Q2018 81 0 43 1243Q2018 53 0 32 854Q2018
Total # of events 180 0 95 275
*Average # of events per month in FY2018: 31
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FY2017 Manual Holds Mechanical Restraints
Locked Seclusion Total events per quarter
1Q2017 91 6 42 1392Q2017 66 1 26 933Q2017 153 0 97 2504Q2017 52 0 33 85
Total # of events 365 7 195 564
*Average # of events per month in FY2017: 47
Action Plan: Staff will receive initial and ongoing education training in the hospital approved Behavior Management Program and Recovery in Action to assist in establishing therapeutic relationships, so when a crisis begins, staff will be more influential and effective in preventing the use of seclusion and restraint.
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.
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