Results Unit Baseline FY 2016 FY 2017 FY 2018 FY 2019 FY 2020 Percent of Target: employees FY 2015 90% who receive 69% 81% the flu vaccination Action Plan: Continue to educate and promote influenza vaccinations. Comments: DDPC is currently hosting its annual Flu Clinic for 2016-2017. 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 Target Baseline 1Q 2Q 3Q 4Q YTD Restraints 2017 2017 2017 2017 2017 2015) Total Restraints 12 39 39 Is order complete? N/A 89% 89% On order, is the intervention stated 100% 87% 87% in behavioral terms? Does the time of the orders match 100% interventions and times on Nursing N/A 94% 94% forms? Is Medical Staff Seclusion and Restraint Progress Note complete 100% 65% 65% (both sides)? Is the time of the 1 hour face to face 100% 100% 100% within an hour of the event?
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% Action Plan: Continue to educate and promote influenza vaccinations. Comments: DDPC is currently hosting its annual Flu Clinic for 2016-2017. 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 Target Restraints Baseline 2015) 1Q 2017 2Q 2017 3Q 2017 4Q 2017 YTD 2017 Total Restraints 12 39 39 Is order complete? N/A 89% 89% On order, is the intervention stated in behavioral terms? 100% 87% 87% 100% Does the time of the orders match interventions and times on Nursing forms? N/A 94% 94% Is Medical Staff Seclusion and Restraint Progress Note complete (both sides)? 100% 65% 65% Is the time of the 1 hour face to face within an hour of the event? 100% 100% 100%
1Q2017.docx