10 10. Dangerous Risk Tool done upon admission 50/50 100% 11 11. of 11 or above incorporated into Safety Problem 12/50 50% 13 N/A 12. Evidence of informed of their rights documentation 47/50 96% 1 Refused 13. Medication Reconciliation @ time of admission includes all 49/50 98% medications (medical & psychiatric) Outpatient Services (OPS) Responsible Party: Lisa Manwaring, Director I. Measure Name: Admission Assessments Measure Description: Within 5 business days of admission initial assessments from Psychiatry, Psychosocial, and Nursing will be complete and in the chart. All three will need to be present to count. Measure Type: Performance Improvement Results Unit Baseline 1Q2016 2Q2016 3Q2016 4Q2016 YTD Percent of FY 2015 75% 75% 75% 75% 75% Target assessments 0% completed 0% 0% 0% 25% .06% 0/4 on time Actual 0/3 0/5 0/4 1/4 1/16 Data Analysis: We had three charts with two assessments completed this quarter. Action Plan: To review data results with the OPS staff to ensure compliance. Comments: To provide education and admission packets with assessment reminders to help facilitate compliance. Peer Support
10 10. Dangerous Risk Tool done upon admission 50/50 100% 11 11. of 11 or above incorporated into Safety Problem 12/50 13 N/A 50% 12. Evidence of informed of their rights documentation 47/50 1 Refused 96% 13. Medication Reconciliation @ time of admission includes all medications (medical & psychiatric) 49/50 98% Outpatient Services (OPS) Responsible Party: Lisa Manwaring, Director I. Measure Name: Admission Assessments Measure Description: Within 5 business days of admission initial assessments from Psychiatry, Psychosocial, and Nursing will be complete and in the chart. All three will need to be present to count. Measure Type: Performance Improvement Results Unit Baseline 1Q2016 2Q2016 3Q2016 4Q2016 YTD Target Percent of assessments completed on time FY 2015 0% 0/4 75% 75% 75% 75% 75% Actual 0% 0/3 0% 0/5 0% 0/4 25% 1/4 .06% 1/16 Data Analysis: We had three charts with two assessments completed this quarter. Action Plan: To review data results with the OPS staff to ensure compliance. Comments: To provide education and admission packets with assessment reminders to help facilitate compliance. Peer Support
Section-13-Riverview-2016Q4.docx