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 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 Inpatient Consumer Survey
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 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. JOINT COMMISSION Inpatient Consumer Survey
2016Q1.docx