Measure Description: The standard goal is to have a sustained level of compliance that approaches and achieves the 90% compliance rate established in the National Flu Initiative for 2020. Employee flu vaccination compliance is measured annually. Type of Measure: Performance Improvement Results Unit Baseline FY 2016 FY 2017 FY 2018 FY 2019 FY 2020 Percent of Target: employees 90% FY 2015 who receive 69% 75% 81% the flu vaccination Data Analysis: So far, FY2017 Data shows a 6% increase in compliance over last fiscal year. Action Plan: Continue to educate staff and promote influenza vaccinations. Medical Staff Dr. Michelle Gardner I. Measure Name: Restraint Documentation Measure Description: Proper documentation is the only way to demonstrate and provide a record that the clinical criteria and assessments for seclusion/restraint have been met. Documentation is critical for patient care/safety, as it validates the care that was provided. Type of Measure: Performance Improvement Results 1Q 2Q 3Q 4Q Baseline YTD Restraints (March 2017 2015) 2017 2017 2017 2017 Total Restraints 12 39 53 27 119 Is order complete? N/A 89% 100% 100% On order, is the intervention stated in 100% 87% 98% 96% 94% behavioral terms? Does the time of the orders match 100% interventions and times on Nursing N/A 94% 96% 100% forms?
Measure Description: The standard goal is to have a sustained level of compliance that approaches and achieves the 90% compliance rate established in the National Flu Initiative for 2020. Employee flu vaccination compliance is measured annually. Type of Measure: Performance Improvement Results Unit Baseline FY 2016 FY 2017 FY 2018 FY 2019 FY 2020 Target: 90% Percent of employees who receive the flu vaccination FY 2015 81% 69% 75% Data Analysis: So far, FY2017 Data shows a 6% increase in compliance over last fiscal year. Action Plan: Continue to educate staff and promote influenza vaccinations. Medical Staff Dr. Michelle Gardner I. Measure Name: Restraint Documentation Measure Description: Proper documentation is the only way to demonstrate and provide a record that the clinical criteria and assessments for seclusion/restraint have been met. Documentation is critical for patient care/safety, as it validates the care that was provided. Type of Measure: Performance Improvement Results Restraints Baseline (March 2015) 1Q 2Q 3Q 4Q YTD 2017 2017 2017 2017 2017 Total Restraints 12 39 53 27 119 Is order complete? N/A 89% 100% 100% On order, is the intervention stated in behavioral terms? 100% 87% 98% 96% 94% 100% Does the time of the orders match interventions and times on Nursing forms? N/A 94% 96% 100%