debriefing completed within 24 hrs of coercive event 15 n/a 100% STRATEGIC PERFORMANCE EXCELLENCE Nursing Department Initial Chart Compliance 2Q2015 All Units – Findings Compliance Indicators 51 of 60 85% GAP note written in appropriate manner at every 24 hours 58 of 60 97% STGs/ Interventions relate directly to content of GAP note. 27 of 60 45% Weekly Summary note completed. Diabetes education Teaching checklist documentation of patient teaching 3 of 60 92% (diabetic patients) 52 n/a Multidisciplinary Teaching checklist active being completed. 57 of 60 97% 1 n/a Dental education Teaching checklist 52 of 60 90% 1 ref., 1 n/a Nursing Assessment of Suicide risk being completed with Treatment Plan 58 of 60 98% review 1 loc Annual Assessment completed. 40 of 60 75% 5 n/a Patient’s rights signed. 41 of 60 80% 4 loc., 3 ref. Treatment Plan Reviewed/Modified Every 2 Weeks 50 of 60 90% 4 n/a Informed Consent signed and dated 35 of 60 68% 4 loc., 2 ref. STG Interventions are clear, simple behavioral actions for nurses 51 of 60 100% 9 n/a STG for patient is behavioral and measurable 44 of 60 88% 9 n/a SRC monitor sheets completed 1 of 60 98% 58 n/a Patient debriefings completed w/in 24 hours after episodes of 1 of 60 98% HOH/SRC/Restraints 58 n/a Safety meeting held 72 hours after coercive event 1 of 60 98% 58 n/a Treatment plan updated after every coercive event 58 n/a 97%
debriefing completed within 24 hrs of coercive event 15 n/a 100% STRATEGIC PERFORMANCE EXCELLENCE Nursing Department Initial Chart Compliance 2Q2015 – All Units Indicators Findings Compliance GAP note written in appropriate manner at every 24 hours 51 of 60 85% STGs/ Interventions relate directly to content of GAP note. 58 of 60 97% Weekly Summary note completed. 27 of 60 45% Diabetes education Teaching checklist documentation of patient teaching (diabetic patients) 3 of 60 52 n/a 92% Multidisciplinary Teaching checklist active being completed. 57 of 60 1 n/a 97% Dental education Teaching checklist 52 of 60 1 ref., 1 n/a 90% Nursing Assessment of Suicide risk being completed with Treatment Plan review 58 of 60 1 loc 98% Annual Assessment completed. 40 of 60 5 n/a 75% Patient’s rights signed. 41 of 60 4 loc., 3 ref. 80% Treatment Plan Reviewed/Modified Every 2 Weeks 50 of 60 4 n/a 90% Informed Consent signed and dated 35 of 60 4 loc., 2 ref. 68% STG Interventions are clear, simple behavioral actions for nurses 51 of 60 9 n/a 100% STG for patient is behavioral and measurable 44 of 60 9 n/a 88% SRC monitor sheets completed 1 of 60 58 n/a 98% Patient debriefings completed w/in 24 hours after episodes of HOH/SRC/Restraints 1 of 60 58 n/a 98% Safety meeting held 72 hours after coercive event 1 of 60 58 n/a 98% Treatment plan updated after every coercive event 58 n/a 97%
2016Q2.docx