Leadership met on Friday, March 6th to review the corrective action steps outlined in the hospital’s response. Quality Improvement Actions Taken During the Measure Quarter Recommendation Prior to his/her treatment Treatment Team Coordinators Treatment Team Coordinators team meeting, the class will document all patient developed & use an audit tool members should be provided engagement in preparation for on each record as it is reviewed the opportunity to meet with a Treatment Team meetings. / revised the day of the team peer specialist in order to The daily chart audit form used meeting. prepare for the discussion and by Treatment Team TTCs handout to the patient, to clearly outline any Coordinators/Auditors will be the is Essential” ‘Your preferences for treatment or updated by Medical Records to form 2-3 days prior to the discharge planning. reflect which patients received meeting and offer to assist the approaches to pre-treatment team meeting patient to complete the form treatment, including engagement. (if needed) prior to the employment, should be meeting. The form is attached consistently explored with and to the treatment plan. If offered to class member, patient refuses to complete the despite disinterest or refusal at from, this is noted on the form the time of admission. and signed by the staff. Riverview's leadership should 100% of patient records will Staff orientation has increased take immediate steps to ensure include documentation of the focus on the principles of that the principles of the patient's into their recovery. As part of this effort Recovery model are clearly individualized treatment plan staff are encouraged to support defined, articulated, and and that the input was used patients with making their supported throughout each of during the Treatment Team needs, goals and life the four units. meeting. expectations made know. Where appropriate and in consistency with the TP, the patients’ comments are incorporated into treatment planning activities. CONSENT DECREE Quality Improvement Actions Taken During the Measure Quarter Recommendation Riverview's clinical leadership The list of case conferences Clinical case conference occurs should work with nursing and and Grand Rounds will be regularly on Thursdays at 12 Mental Health Worker staff to maintained. The roster of staff noon. In addition, longer design and implement case participation will be audiovisual conferences with conferences or Grand Rounds maintained by the Staff and faculty at Dartmouth College so that there is greater Organizational Development three times per year and knowledge, skills, and support Office. These data will be will move to a similar Thursday noon slot for the
Leadership met on Friday, March 6th to review the corrective action steps outlined in the hospital’s response. Recommendation Quality Improvement Measure Actions Taken During the Quarter Prior to his/her treatment team meeting, the class members should be provided the opportunity to meet with a peer specialist in order to prepare for the discussion and to clearly outline any preferences for treatment or discharge planning. approaches to treatment, including employment, should be consistently explored with and offered to class member, despite disinterest or refusal at the time of admission. Treatment Team Coordinators will document all patient engagement in preparation for Treatment Team meetings. The daily chart audit form used by Treatment Team Coordinators/Auditors will be updated by Medical Records to reflect which patients received pre-treatment team meeting engagement. Treatment Team Coordinators developed & use an audit tool on each record as it is reviewed / revised the day of the team meeting. TTCs handout to the patient, the ‘Your is Essential” form 2-3 days prior to the meeting and offer to assist the patient to complete the form (if needed) prior to the meeting. The form is attached to the treatment plan. If patient refuses to complete the from, this is noted on the form and signed by the staff. Riverview's leadership should take immediate steps to ensure that the principles of the Recovery model are clearly defined, articulated, and supported throughout each of the four units. 100% of patient records will include documentation of the patient's into their individualized treatment plan and that the input was used during the Treatment Team meeting. Staff orientation has increased focus on the principles of recovery. As part of this effort staff are encouraged to support patients with making their needs, goals and life expectations made know. Where appropriate and in consistency with the TP, the patients’ comments are incorporated into treatment planning activities. CONSENT DECREE Recommendation Quality Improvement Measure Actions Taken During the Quarter Riverview's clinical leadership should work with nursing and Mental Health Worker staff to design and implement case conferences or Grand Rounds so that there is greater knowledge, skills, and support The list of case conferences and Grand Rounds will be maintained. The roster of staff participation will be maintained by the Staff and Organizational Development Office. These data will be Clinical case conference occurs regularly on Thursdays at 12 noon. In addition, longer audiovisual conferences with faculty at Dartmouth College three times per year and will move to a similar Thursday noon slot for the
2016Q1.docx