Is Medical Staff Seclusion and Restraint Progress Note complete 100% 44% 44% (both sides)? Is the time of the 1 hour face to face 100% 100% 100% within an hour of the event? If PA, did PA consult with attending? 92% 100% 100% Are the details of the similar on 100% 100% 100% all forms? Did the medical provider participate in the Seclusion and Restraint N/A 100% 100% treatment plan review? Overall Compliance 96% 84% 84% Goal: 100% Compliance with Medical Staff Documentation Data Analysis: There were 12 seclusions in the 1st quarter. The overall compliance rate decreased 12%: from 96% in 4th quarter FY2016 to 84% 1st quarter FY2017. The plan moving forward is to continue to monitor compliance with the above Action Plan: data elements and to discuss and address non-compliance with the medical staff. III. Measure Name: All elements of a medication order are complete. To promote safe medication ordering by defining the required Measure Description: elements of a complete medication order. Performance Improvement Type of Measure: Baseline Total Data Elements 1Q2017 2Q2017 3Q2017 4Q2017 4Q2016 Compliance # of Medication orders 245 258 258 reviewed Medication order sheet has patient name, DOB and 100% 100% 100% hospital number ID (2 patient identifiers)? Date and time of the order 99% 99% 99% Medication name 99% 100% 100%
Is Medical Staff Seclusion and Restraint Progress Note complete (both sides)? 100% 44% 44% Is the time of the 1 hour face to face within an hour of the event? 100% 100% 100% If PA, did PA consult with attending? 92% 100% 100% Are the details of the similar on all forms? 100% 100% 100% Did the medical provider participate in the Seclusion and Restraint treatment plan review? N/A 100% 100% Overall Compliance 96% 84% 84% Goal: 100% Compliance with Medical Staff Documentation Data Analysis: There were 12 seclusions in the 1st quarter. The overall compliance rate decreased 12%: from 96% in 4th quarter FY2016 to 84% 1st quarter FY2017. Action Plan: The plan moving forward is to continue to monitor compliance with the above data elements and to discuss and address non-compliance with the medical staff. III. Measure Name: All elements of a medication order are complete. Measure Description: To promote safe medication ordering by defining the required elements of a complete medication order. Type of Measure: Performance Improvement Data Elements Baseline 4Q2016 1Q2017 2Q2017 3Q2017 4Q2017 Total Compliance # of Medication orders reviewed 245 258 258 Medication order sheet has patient name, DOB and hospital number ID (2 patient identifiers)? 100% 100% 100% Date and time of the order 99% 99% 99% Medication name 99% 100% 100%
1Q2017.docx