Patients who do not meet criteria for metabolic syndrome 10 Patients who cannot be classified at this time 13 VI. Measure Name: Veriform Medication Room Audits Measure Description: Quarterly Completion by Unit Audits Type of Measure: Quality Assurance Results Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD Unit Target 100% 100% 100% 100% 100% FY2017 All 100% Actual 100% 100% Monthly, the Pharmacy Department performs comprehensive inspections of medication Methodology: rooms, central supply areas, and the medical clinic. Over 44 criteria are monitored in the audits utilizing Veriform software. Data Analysis: The medication room audits have been concluded for 1Q2018 without completion deficiencies. Pharmacy continues to strive for audits that are 100% complete The Pharmacy Department will continue to send reminders early in the process to ensure Action Plan: that completion, compliance, verification and reporting is performed in a timely fashion. Comments: Continuous monitoring of the medication room audits and approval by the responsible individuals has provided satisfactory results for this quarter. VII. Measure Name: Medication Dispensing Process Baseline Unit Goal 1Q2018 2Q2018 3Q2018 4Q2018 4Q2016 Measure Controlled Substance Loss Data: Pyxis-CII Safe Target: 0% All 0% Compare Report. Actual: 0% Monthly CII Safe Vendor Target: 0 Rx 0 Receipt Report. Actual: 0 Monthly Pyxis Unresolved 0 0/ Target: Controlled Drug All 14 month Actual: Discrepancies. (4.66/mo)
Patients who do not meet criteria for metabolic syndrome 10 Patients who cannot be classified at this time 13 VI. Measure Name: Veriform Medication Room Audits Measure Description: Quarterly Completion by Unit Audits Type of Measure: Quality Assurance Results Unit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD Target All FY2017 100% 100% 100% 100% 100% 100% Actual 100% 100% Methodology: Monthly, the Pharmacy Department performs comprehensive inspections of medication rooms, central supply areas, and the medical clinic. Over 44 criteria are monitored in the audits utilizing Veriform software. Data Analysis: The medication room audits have been concluded for 1Q2018 without completion deficiencies. Pharmacy continues to strive for audits that are 100% complete Action Plan: The Pharmacy Department will continue to send reminders early in the process to ensure that completion, compliance, verification and reporting is performed in a timely fashion. Comments: Continuous monitoring of the medication room audits and approval by the responsible individuals has provided satisfactory results for this quarter. VII. Measure Name: Medication Dispensing Process Measure Unit Baseline 4Q2016 Goal 1Q2018 2Q2018 3Q2018 4Q2018 Controlled Substance Loss Data: Pyxis-CII Safe Compare Report. All 0% Target: Actual: 0% 0% Monthly CII Safe Vendor Receipt Report. Rx 0 Target: Actual: 0 0 Monthly Pyxis Unresolved Controlled Drug Discrepancies. All 0/ month Target: Actual: 0 14 (4.66/mo)
DDPCQuarterlyReport1Q2018.docx