Is order complete? N/A 72% 100% On order, is the intervention stated in 92% 56% 97% 100% 84% behavioral terms? Does the time of the orders match Target interventions and times on Nursing N/A 100% 93% 100% 98% 100% forms? Is Medical Staff Seclusion and Restraint Progress Note complete 100% 44% 100% (both sides)? Is the time of the 1 hour face to face 100% 100% 94% 100% 98% within an hour of the event? If PA, did PA consult with attending? 92% 100% 83% 100% 94% Are the details of the event similar on 100% 100% 100% all forms? Did the medical provider participate in the Seclusion and Restraint treatment N/A 100% 92% 94% 95% plan review? Overall Compliance 96% 84% 95% 93% 99% Data Analysis: There were 12 seclusion events in the 1Q2017 with an overall compliance of 84%. 2Q2017 shows an increase in seclusion events to 27, with a significant increase in overall compliance to 95%; 11% above 1st Quarter. 3Q2017 shows a decrease to 9 seclusions events with an overall compliance of 99%: 4% above 2Q2017 and 15% above 1Q2017. Medical Staff has met the goal for three data elements of measurement by meeting the 100% goal for 4 consecutive months. Questions “Is order complete” “Is Medical Staff Seclusion and Restraint Progress Note complete (both sides)?” and “Are the details of the event similar on all forms?” will be removed from aggregation and will be evaluated by spot check in 6 months to evaluate and ensure consistent and reliable documentation compliance. Goal: 100% Compliance with Medical Staff Documentation Action Plan: The plan moving forward is to continue to monitor compliance with the above data elements and to discuss and address non-compliance with the Medical Staff. III. Measure Name: All elements of a medication order are complete.
Is order complete? N/A 72% 100% On order, is the intervention stated in behavioral terms? 92% 56% 97% 100% 84% Target 100% Does the time of the orders match interventions and times on Nursing forms? N/A 100% 93% 100% 98% Is Medical Staff Seclusion and Restraint Progress Note complete (both sides)? 100% 44% 100% Is the time of the 1 hour face to face within an hour of the event? 100% 100% 94% 100% 98% If PA, did PA consult with attending? 92% 100% 83% 100% 94% Are the details of the event similar on all forms? 100% 100% 100% Did the medical provider participate in the Seclusion and Restraint treatment plan review? N/A 100% 92% 94% 95% Overall Compliance 96% 84% 95% 99% 93% Data Analysis: There were 12 seclusion events in the 1Q2017 with an overall compliance of 84%. 2Q2017 shows an increase in seclusion events to 27, with a significant increase in overall compliance to 95%; 11% above 1st Quarter. 3Q2017 shows a decrease to 9 seclusions events with an overall compliance of 99%: 4% above 2Q2017 and 15% above 1Q2017. Medical Staff has met the goal for three data elements of measurement by meeting the 100% goal for 4 consecutive months. Questions “Is order complete” “Is Medical Staff Seclusion and Restraint Progress Note complete (both sides)?” and “Are the details of the event similar on all forms?” will be removed from aggregation and will be evaluated by spot check in 6 months to evaluate and ensure consistent and reliable documentation compliance. Goal: 100% Compliance with Medical Staff Documentation Action Plan: The plan moving forward is to continue to monitor compliance with the above data elements and to discuss and address non-compliance with the Medical Staff. III. Measure Name: All elements of a medication order are complete.
3Q2017.docx