Type of Measure: Performance Improvement Results Target 1Q 2Q 3Q 4Q Baseline YTD Seclusions (March 2017 2017 2017 2017 2017 2015) Total Seclusions 7 12 27 39 Is order complete? N/A 72% 100% 86% On order, is the intervention stated 92% 56% 97% 77% in behavioral terms? Does the time of the orders match 100% interventions and times on Nursing N/A 100% 93% 97% forms? Is Medical Staff Seclusion and Restraint Progress Note complete 100% 44% 100% 72% (both sides)? Is the time of the 1 hour face to face 100% 100% 94% 97% within an hour of the event? If PA, did PA consult with attending? 92% 100% 83% 92% Are the details of the event similar 100% 100% 100% 100% on all forms? Did the medical provider participate in the Seclusion and Restraint N/A 100% 92% 96% treatment plan review? Overall Compliance 96% 84% 95% 89% Data Analysis: There were 12 seclusion events in the 1st quarter FY2017 with an overall compliance of 84%. 2nd Quarter shows an increase in seclusion events to 27, with a significant increase in overall compliance to 95%; 11% above 1st Quarter and 1% below baseline. Medical Staff has met the goal for three data elements of measurement by meeting the 100% goal for 4 consecutive months. Questions “Is order complete” “Is Medical Staff Seclusion and Restraint Progress Note complete (both sides)?” and “Are the details of the event similar on all will be removed from aggregation and will be evaluated by spot check in 6 months to forms?” evaluate and ensure consistent and reliable documentation compliance.
Type of Measure: Performance Improvement Results Target Seclusions Baseline (March 2015) 1Q 2Q 3Q 4Q YTD 2017 2017 2017 2017 2017 Total Seclusions 7 12 27 39 Is order complete? N/A 72% 100% 86% On order, is the intervention stated in behavioral terms? 92% 56% 97% 77% 100% Does the time of the orders match interventions and times on Nursing forms? N/A 100% 93% 97% Is Medical Staff Seclusion and Restraint Progress Note complete (both sides)? 100% 44% 100% 72% Is the time of the 1 hour face to face within an hour of the event? 100% 100% 94% 97% If PA, did PA consult with attending? 92% 100% 83% 92% Are the details of the event similar on all forms? 100% 100% 100% 100% Did the medical provider participate in the Seclusion and Restraint treatment plan review? N/A 100% 92% 96% Overall Compliance 96% 84% 95% 89% Data Analysis: There were 12 seclusion events in the 1st quarter FY2017 with an overall compliance of 84%. 2nd Quarter shows an increase in seclusion events to 27, with a significant increase in overall compliance to 95%; 11% above 1st Quarter and 1% below baseline. Medical Staff has met the goal for three data elements of measurement by meeting the 100% goal for 4 consecutive months. Questions “Is order complete” “Is Medical Staff Seclusion and Restraint Progress Note complete (both sides)?” and “Are the details of the event similar on all forms?” will be removed from aggregation and will be evaluated by spot check in 6 months to evaluate and ensure consistent and reliable documentation compliance.