Medication dose 96% 97% 97% Route of administration 94% 97% 97% Frequency of administration and/or 92% 98% 98% dosing interval Indication for use 90% 96% 96% Authorized prescribers 97% 98% 98% signature and credentials Telephone orders completed, signed, 97% 100% 100% and timed w/in 72 hr. Overall Compliance 93% 98% 98% Data Analysis: Six data elements were found to be below the established goals of 100% for the 1st quarter; however, all have shown an improvement from 4th quarter FY2016. The data elements remain above the threshold of 90% compliance. Action Plan: Continue to monitor. Nursing Janet Babcock, RN I. Measure Name: Restraint Audits Patient Safety – Proper documentation is the only way to demonstrate and Measure Description: 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. The audits were initiated January of 2015. Performance Improvement Type of Measure: Results 1Q 2Q 3Q 4Q Target Data Elements YTD 2017 2017 2017 2017 4Q2016 # of Events 100% 35 39 39
Medication dose 96% 97% 97% Route of administration 94% 97% 97% Frequency of administration and/or dosing interval 92% 98% 98% Indication for use 90% 96% 96% Authorized prescribers signature and credentials 97% 98% 98% Telephone orders completed, signed, and timed w/in 72 hr. 97% 100% 100% Overall Compliance 93% 98% 98% Data Analysis: Six data elements were found to be below the established goals of 100% for the 1st quarter; however, all have shown an improvement from 4th quarter FY2016. The data elements remain above the threshold of 90% compliance. Action Plan: Continue to monitor. Nursing Janet Babcock, RN I. Measure Name: Restraint Audits – Patient Safety 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. The audits were initiated January of 2015. Type of Measure: Performance Improvement Results Target Data Elements 4Q2016 1Q 2017 2Q 2017 3Q 2017 4Q 2017 YTD 100% # of Events 35 39 39
1Q2017.docx