JOINT COMMISSION Dispensing Process 1Q Baseline 2Q 3Q 4Q 2016 Measure Unit 2014 Goal 2015 2015 2015 1. Controlled Substance Loss Data: All 0.875% 0% Daily Pyxis-CII Safe Compare Target: 0% 0% 0% 0% Report. Actual: 0% 0% 0% 0% 2. Controlled Substance Loss Data: Rx 0 0 Monthly CII Safe Vendor Receipt Target: 0 0 0 0 Report. Actual: 0 0 0 0 3. Controlled Substance Loss Data: All 22/mo 0 Monthly Controlled Drug Target: 0 0 0 0 discrepancies. Actual: 66 42 37 22 (22/ (14/ (12/ 7/ mo) mo) mo) mo 4. Medication Management Rx 8/year 0 Monitoring: Measures of drug Target: 0 0 0 0 reactions, adverse drug events and Actual: 1 2 3 0 other management data. 5. Medication Management Rx 99/ 100% Monitoring: Resource quarter Target: 100% 100% 100% 100% Documentation Reports of Clinical Actual: 79 73 56 31 Interventions. 6. Psychiatric Emergency Process: All 100% 100% Monthly audit of all psych Target: 100% 100% 100% 100% emergencies measures against 9 Actual: 95% 93% 94% 78% criteria. 7. Operational Audit: Rx 100% 100% Monthly audit of 3 operational Target: 100% 100% 100% 100% indicators from CPS contract. Actual: 100% 100% 100% 100% 1Q2016: 6. One psych emergency (PE) was reported during the quarter. Two of the nine criteria were not met: MAR/s printed/brought to unit by RPh and PH checking new MARs vs. updated MARs completing by nursing & reconciliation performed. The PE ended over the weekend and it is unclear if the protocol was followed. Re-education will be done to correct the process.
JOINT COMMISSION Dispensing Process Measure Unit Baseline 2014 Goal 2Q 2015 3Q 2015 4Q 2015 1Q 2016 1. Controlled Substance Loss Data: Daily Pyxis-CII Safe Compare Report. All 0.875% 0% Target: Actual: 0% 0% 0% 0% 0% 0% 0% 0% 2. Controlled Substance Loss Data: Monthly CII Safe Vendor Receipt Report. Rx 0 0 Target: Actual: 0 0 0 0 0 0 0 0 3. Controlled Substance Loss Data: Monthly Controlled Drug discrepancies. All 22/mo 0 Target: Actual: 0 66 (22/ mo) 0 42 (14/ mo) 0 37 (12/ mo) 0 22 7/ mo 4. Medication Management Monitoring: Measures of drug reactions, adverse drug events and other management data. Rx 8/year 0 Target: Actual: 0 1 0 2 0 3 0 0 5. Medication Management Monitoring: Resource Documentation Reports of Clinical Interventions. Rx 99/ quarter 100% Target: Actual: 100% 79 100% 73 100% 56 100% 31 6. Psychiatric Emergency Process: Monthly audit of all psych emergencies measures against 9 criteria. All 100% 100% Target: Actual: 100% 95% 100% 93% 100% 94% 100% 78% 7. Operational Audit: Monthly audit of 3 operational indicators from CPS contract. Rx 100% 100% Target: Actual: 100% 100% 100% 100% 100% 100% 100% 100% 1Q2016: 6. One psych emergency (PE) was reported during the quarter. Two of the nine criteria were not met: MAR/s printed/brought to unit by RPh and PH checking new MARs vs. updated MARs completing by nursing & reconciliation performed. The PE ended over the weekend and it is unclear if the protocol was followed. Re-education will be done to correct the process.
Section-13-Riverview-Report-FY16Q1.docx