within 5 more days if extension is requested? *Overall Compliance of Nursing Supervisor and Social Worker 80% 85% 85% addressing grievance Element 1: Unit Staff compliant with addressing grievance Element 2: Unit Staff completed form correctly and notified Nurse Supervisor Element 3: Nurse Supervisor addressed grievance within four hours Element 4: Nurse Supervisor completed form correctly and forwarded to Social Worker Element 5: Social Worker addressed grievance within five days or more than five days if extension is requested Element 6: Overall Compliance of Nursing Supervisor and Social Worker Addressing Grievance Data Analysis: All data elements decreased from 4Q2017 to 1Q2018. Overall compliance for Nursing Supervisor and Social Worker addressing grievance decreased from 98% to 85%. Action Plan: Working on finalization of new complaint and grievance form which are more clearly marked where documentation and signatures are needed. With revision of grievance policy will seek 24-hour response time instead of four hours by CNM or nurse supervisor to allow staff time to gather information and meet with patients during the day when they are not available during the day. Further training by patient advocates and management for unit staff would be beneficial as well. Continue to provide feedback to Director of Nursing and supervisors when forms are not completed correctly. Staff Education and Development Jenny Bamford-Perkins, MSN, RN Measure Name: Mandatory Staff Education Measure Description: Both direct and non-direct care employees of Dorothea Dix Psychiatric Center are required to complete monthly mandatory staff education. The Staff Education Department will conduct monthly audits using the education database. Type of Measure: Performance Improvement Methodology: The numerator will be the number of staff that completed their monthly education requirements for the quarter and the denominator will be the total number of staff for the quarter. The goal is to have 100% compliance of monthly education requirements by the staff education year end in 2Q of each fiscal year.
within 5 more days if extension is requested? *Overall Compliance of Nursing Supervisor and Social Worker addressing grievance 80% 85% 85% Element 1: Unit Staff compliant with addressing grievance Element 2: Unit Staff completed form correctly and notified Nurse Supervisor Element 3: Nurse Supervisor addressed grievance within four hours Element 4: Nurse Supervisor completed form correctly and forwarded to Social Worker Element 5: Social Worker addressed grievance within five days or more than five days if extension is requested Element 6: Overall Compliance of Nursing Supervisor and Social Worker Addressing Grievance Data Analysis: All data elements decreased from 4Q2017 to 1Q2018. Overall compliance for Nursing Supervisor and Social Worker addressing grievance decreased from 98% to 85%. Action Plan: Working on finalization of new complaint and grievance form which are more clearly marked where documentation and signatures are needed. With revision of grievance policy will seek 24-hour response time instead of four hours by CNM or nurse supervisor to allow staff time to gather information and meet with patients during the day when they are not available during the day. Further training by patient advocates and management for unit staff would be beneficial as well. Continue to provide feedback to Director of Nursing and supervisors when forms are not completed correctly. Staff Education and Development Jenny Bamford-Perkins, MSN, RN Measure Name: Mandatory Staff Education Measure Description: Both direct and non-direct care employees of Dorothea Dix Psychiatric Center are required to complete monthly mandatory staff education. The Staff Education Department will conduct monthly audits using the education database. Type of Measure: Performance Improvement Methodology: The numerator will be the number of staff that completed their monthly education requirements for the quarter and the denominator will be the total number of staff for the quarter. The goal is to have 100% compliance of monthly education requirements by the staff education year end in 2Q of each fiscal year.
DDPCQuarterlyReport1Q2018.docx