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Quality Improvement &Governance with DataCAPT AMY BUCKANAGA, RN MSNBEMIDJI AREA ACTING DIRECTOR OF QUALITY /FIELD NURSE CONSULTANT
The State of Health Care Today Providers are becoming more specialized,leading to gaps in communication and care Populations are aging, with disease burdenshifting toward chronic conditions Patients and families are better informed,wanting more personalized care Complicated procedures and expensivetreatments are more available and desired
New Quality Framework toGuide Delivery of Care at IHS In 2016 the IHS Quality Framework developed to outline how the IHS will develop,implement, and sustain an effective quality program to:1.2.3.4.5.Strengthen Organizational Capacity to Improve Quality of Care andSystemsMeet and Maintain Accreditation for IHS Direct Service FacilitiesAlign Service Delivery Processes to Improve Patient ExperienceEnsure Patient SafetyImprove Transparency and Communication Regarding Patient Safetyand Quality to IHS Stakeholders The Quality Framework was developed by assessing current IHS quality policies,practices, and programs, incorporating standards from national experts, consulting withtribal leaders and including best practices from across the IHS system of care.3
IHS Model
What is Governance?To govern is to steer, to control, and to influence from aposition of authority. Governance deals with the legitimatedistribution of authority throughout a system – whether acountry or an organization.-- BoardSource
CMS Conditions ofParticipationTo qualify for Medicare certification and reimbursement, providers andsuppliers of health services must comply with minimum health andsafety standards. “Conditions of Participation” (“CoPs”) or “Conditions for Coverage” (“CfCs”), depending on the type of Medicareparticipating entity.They are embodied in Title XVIII of the Social Security Act (“SSA”) andother regulations that the Secretary of the Department of Health andHuman Services (“DHHS”) find to be necessary and in the interest of thehealth and safety of individuals who receive services in the institution,as authorized by SSA.
CMS and the Governing BoardThe Governing Board is responsible for the entire Medicarecertified hospital/clinic and CMS holds it accountable for thequality of care provided and the facility’s compliance withall Medicare applicable Conditions of Participations (CoP)
DynamicOrganizationMission Goals Strategic Direction
Process ImprovementTop-DownStaff DrivenLeaderDrivenBottomUp
GOODCAUTIONPOORn/a not availableBemidji Area - [SU Name]FISCAL AXIMIZE RESOURCES:CHS: [Staff name]Open Documents: % open 90 days/alldocuments for quarterOpen 90 daysTotal documents (Paid, open, cancelled)good 25%great 10%Stay within budgetallocation 80% good 90% caution 100% alertCHS ExpendituresTotal BudgetedObiligatedExpendedRevenue Generation: [Staff Name]Third party oal 25%caution 26-49%alert 50%Denials: MedicareClaims deniedClaims generatedgoal 25%caution 26-49%alert 50%Denials: MedicaidClaims deniedClaims generatedAged accountsData Entry: [DE supervisor](Days from service to data entry)Overall Budget: [Budget Analyst]Total BudgetedExpendituresgoal 25%caution 26-49%alert 50%great 24 hoursgood 2-10 daysalert 10 daysPercent of budgetexpendedBAO BSC 2007
pMEDICAL RECORDS: [ MR supervisor]Signing verbal/telephone orders within 24Completion of H&P within 24 hoursMedical Record Delinquency Rate**Number of Medical Staff reviewed InpatientrecordsNumber of Medical Staff reviewed ER/Otptrecords100%100%Great 24 hoursgood 2-10 daysalert 10 daysGPRA-HP/DP Performance Improvement Coordinator - See GPRA Dashboard attachedInfection Control: 1.0%Nosocomial infection rateNumber of OSHA recordable workerinjuries/illnessesEnvironment of Care:Safety ManagementxxxEOC rounds identified issues correctedxxxEOC rounds identified issues100%EOC % Issues corrected**AnnualPlan up to datexxxAnnual report to governing body (date)Security Management 5Security IncidentsAnnualPlan up to dateAnnualAnnual report to governing body (date)Life Safety Program1st shiftFire Drills (date)2nd shiftSmoke Detector Test (date)Extinguisher Inspection (date)Semi-annualMonthlyEmergency Lighting Test (date)MonthlyFire Alarm System Test (date)Plan up to dateAnnual report to governing body (date)Hazardous Materials and WasteHaz Chem Inventory (date)Biohaz waste disposalPlan up to dateAnnual report to governing body (date)QuarterlyAnnualdue 4thYearlygallonsBi AnnualDue 4thBAO BSC 2007
Medical Equipment and Management0%SMDA IncidentsrateMed Equip FailuresAnnualPlan up to dateDue 4thAnnual report to governing body (date)Utility Management# of incidentsUtility FailuresAnnualPlan up to dateDue 4thAnnual report to governing body (date)Emergency PlanningAnnualDisaster Drills-Externalsemi-annualDisaster Drills-InternalAnnualPlan up to dateDue 4thAnnual report to governing body (date)PHYSICAL RESOURCES (Insert dates of completion)FEDS ReportBiomedical Equipment ReportAnnual Equipment Inventory ReviewIT-Computer Equipment ReviewCompletedannuallyIMPROVE MANAGEMENT:HUMAN RESOURCES:Competency assessment completedwithin 30 days( # of employees)Total New Employees - Applicable% CompliancePMAP Implementation for newemployees within 30 daysTotal Employees - Applicable% CompliancePMAP, Completion of Final (# of employeesapplicable, not including commissioned corp 120 days supervision )Total Employees (# of employees applicable, not includingcommissioned corp 120 days supervision)% ComplianceIndividual Development Plan, Completion of(# of employees)Total Employees% ComplianceEmployee/Contractor Background checks(completed within 7 days)New Employee/Contractors% ComplianceVacancy Rate (vacancies/total positions)Turnover (positions vacated/total xx100%100% 5% 5%BAO BSC 2007
(pp)Medical Staff Reappointment - MedStaff Secretary# due for reappointment# re-appointed% Compliance**100%100%MAXIMIZE HEALTH RETURNS: PATIENT PERSPECTIVERegulatory Compliance and AccreditationRecommendations from Survey bylicensing, accrediting or certifying body% of Patient Satisfaction Surveys# of patient complaintsTotal number of visits% of patient complaintsClinical Safety: PharmacistPrescriptions filledSignificant medication events (Category D-Ior above)Rate of significant adverse medicationevents D-I or aboveClinical Safety: Nursing/Medical StaffNumber of patient injuriesNumber of patient fallsCategory D-I 2%Great - 0good 1BAO BSC 2007
OPERATIONS:1. Service Unit Projected Budget:Projected AllowancesProjected CollectionsPY Carryover budgetEquipment Allowance including PYEquipment CarryoverTotal FundingSalary ExpenseBenefit ExpenseTravel ExpenseTransportation ExpenseUtilities/Rent/Comm ExpensePrinting ExpenseTemporary Help Services ExpenseTraining ExpenseContractual Service ExpensePharmacy Supply ExpenseMedical/Dental Supply ExpenseLaboratory Supply ExpenseAdministrative/Stock SupplyExpenseEquipment ExpenseMedical Equipment ExpenseCommitmentsLoan PaymentOther Expense not IdentifiedTotal Projected ExpensesActual Balance (carryover)2. Business Office:Affordable Care Act EnrollmentsBilling Backlog by # claimsPending Claims ReportNumber of Aged Claims Amount of Aged ClaimsBemidji Area Scorecard FY2018 0Q1Q2Q3Q4ActualsActualsActualsActuals TotalObligated 0 0 0 0 0 0 0 0 0 0 0 0 0Last Year Total 0 0QQ1 0 0Q2 0 0Q3 0 0Q4 0 0Total 0 0 0 0 0 0 00000 0BAO BSC 2018
3. PRCActual PRC AllowancesLast Year TotalQQ1Q2Q3Q4Total 0Sum of Current Year Funds AvailablePrior Year Funds Available (X Funds)Total of Undelivered Orders(FY13-FY14-FY15-FY16)Total CHEF Cases SubmittedTotal CHEF Eligible CasesTotal Dollar Amount for CHEF Casesbefore Reconciliation4. Meaningful UseDid your facility meet MU in 2017Did your facility meet MIPS in 2017Are you on tract to meet MU in 18Are you on tract to meet MIPS in 185. Contracting# of New Requests Received inPRISMNumber of Requistions AwardedNumber of Requistions CanceledHUMAN CAPITAL:6. Position Control:Total Budgeted FTE PositionsTotal Filled FTE PositionsTotal Unfilled FTE PositionsVacancy Rate:Unbudgeted Position RequestsPositions Filled by a ContractorNew HiresResignationsTransfers to other IHS FacilityTerminationsTerminated on ProbationRetirements 0 0 000 0TotalQQ1Q2Q3Q40000Total000Last Year /0!Total#DIV/0!00000000BAO BSC 2018
Transfers to other IHS FacilityTerminationsTerminated on ProbationRetirementsTotal ExitsDocumented Exit Interviews% of Completed exit interviews# with Recruitment Incentive# with Retention Incentive# with Relocation Incentive7. BAO HR:Positions SubmittedIncomplete Track-It TicketsAverage Time from Submission toAdvertised PositionAverage Time from Panel toSelection:Average Time from Selection toStart DateQUALITY AND ACCESS TO CARE:8. Total ER & UC VisitsEmergency Room VisitsUrgent Care VisitsLeft Without Being Seen (LWBS)9. Total Primary Care Visits:Average # of days to 3rd nextavailable appointment (PrimaryCare Medical Clinics excludingPediatric)Average # of days 3rd nextavailable appointment (Pediatricclinic)10. Ancillary Services Workload:Lab Tests AccessionedRadiology Exams !Q1Q2Q3Q4000000#DIV/0!Total0Last Year TotalLast Year 0.000.000.000.000.00Q3Q4Total00BAO BSC 2018
11. Hospital Services Workload:Last Year TotalInpatient AdmissionsInpatient DaysSwing bed AdmissionsSwing bed DaysAverage Length of Stay (ALOS)Average Daily Patient Load (ALDP)12. Pharmacy Visit DataLast Year TotalTotal Prescriptions filledTotal Pharmacy VisitsRXs Controlled SubstancesDispensedAverage Morphine MilligramEquivalent (MME)RX (RRIP)# of hydrocodone tablets dispensed(all strengths)Number of patients with averageMME 90 (RRIP)Number of patients with concurrentopioid BZD (RRIP)Number naloxone units dispensed(DUER)Average Cost/RXPoint of Service (POS) Revenue(A/R)Clinical Billing Revenue (B/O)TRANSPARENCY AND ACCOUNTABILITY:13. Communication:Last Year TotalDate/Number of CEO quarterlycommunication to the TribeDates of Partnership activities withtribal and other stakeholdersDate of CEO quarterlycommunication to StaffDate of attendance at a TribalCouncil MeetingQ1Q2Q3Q4Q1Q2Q3Q400000000000000 - Q1Q2Q3-Q4BAO BSC 2018
gPositive Feedback CasesNegative Feedback Cases14. Medical Staff Priviliging# of Initial Appointments# of Rapid Privileges Granted# of reappointmentsAppointments or privileges denied# working with expired privileges# working with expired license# of Disciplinary Action# of Reports to NPDB or LicensingAuthorities15. License VerificationNursing Licenses ValidatedLast Year TotalQ1Q2Q300Q400000000100 % validationQ1Q2Q3Q400Active Med Staff Licenses ValidatedAllied Health Staff LicensesValidatedAssociate Med Staff Licenses000Lab Staff Verified Certification ASCPDental Staff Verified License (NotDDS)Radiology Staff Verified CertifiedARRT00Key:Active Medical Staff Physicians, Dentists, Podiatrists, Advance practice Nurse practitioners, Licensed Independent Clinical Psychologists, OptometristsAllied Health Staff Pharmacists, Physician Assistants, Licensed Clinical Social Workers, Physical Therapists,/Occupational Therapists, AudiologistAssociated Med Staff Contractors (locums & specialists); Consultants, part time staff of less than 20 hours, or LIP volunteersADDITIONAL REPORTS DUE QUARTERLYComplete Operation Summary Report by dates; yearGPRAQI SnapshotIC DashboardEoC & Safety Dashboard3rd Party Graphs (BAO will provide)Satisfaction SurveysQ1Q2Q3Q4FinalBAO BSC 2018
{Insert Facility Name} Environment of Care Reporting Dashboard - Fiscal Year 2018Quality Assurance/Performance Improve/Risk Management Internal/Deliberative DocumentEnvironment of Care, Life Safety, and Emergency Management RequirementsC COMPLETE; X INCOMPLETE, S SCHEDULED, N/A Not BRRGPLYNEOC/Safety Committee Meeting 2Safety Officer(X)N/A4Management Plans/Policies and Annual Evaluations (AAAHC facilities may fulfill these reporting requirements with policies/procedures for these subject areas)Safety Officer/Safety & SecuritySafety ManagementXCommitteeSecurity Supervisor/SafetySecurityOfficer/Safety & SecurityCommitteeHazardous Material & WasteSafety Officer/FacilitiesSafety Officer /Facilities /SafetyFire Safety& Security CommitteeFacility Management/Safety &UtilitySecurity CommitteeBiomed/Safety & SecurityMedical EquipmentCommitteeSafety Officer/Safety & SecurityEmergency Operations PlanXCommitteeSafety Officer/Safety & SecurityCommitteeXSafety Management Risk AssessmentSecurity/Safety & SecuritySecurity Risk AssessmentXCommitteeMock SurveysIf completed before FY 2018, enter date here PerformedArea Officeevery 3yrsCorrective ActionsMulti-Disciplinaryevery 3yrsEnvironmental RoundsClinical EnvironmentSafety OfficerXN/ANon-Clinical EnvironmentSafety OfficerXN/AConsultant ReportsIf completed before FY 2018, enter date here 3Facility Mgt/Safety/IEHrel pressure 3X ACHVentilation Testing (Isolation, OR)3Facility Mgt/Safety/IEHX ACH 3rel pressureVentilation Testing(CSR, Soiled Utility Rm)3Facility Mgt/Safety/IEHrel pressure 3X ACHVentilation Testing (Lab: Gen, Bact, Path.)Rad Protection Surveys-MedIEHevery 2yrsRad Protection Surveys-DentalIEHevery 3yrsNitrous Oxide Monitoring (Dental, Cryo)IEHevery 2yrsOther Routine IEH Consultant SurveysN/AREEmergency ManagementExercises (Code Blue/Disaster)Safety & Security CommitteeXEOPSafety & Security CommitteeREHazard Vulnerability Assessment (HVA)Safety & Security CommitteeXN/A - WESU AAAHC not TJCRE96-Hour Evaluation & EM Inventory 4 (TJC only)COOPSafety & Security CommitteeRELife Safety/Fire SafetyFire DrillsDay ShiftSafety OfficerXN/AEvening ShiftSafety OfficerXN/ANight ShiftFacility ManagementXN/AHealth Centers: NameFacility ManagementXFire ExtinquishersInspectionMaintenance StaffXMaintenanceContractX4 (TJC only)N/A - AAAHC not TJCStatement of Conditions (TJC)Xsee Tab "Facility Dashboard". Missing PM's need notes in QTR CommentsPM's for Life Safety and Utility SystemsFacilities ManagementX ACTION, RE thlyQuarterlySemi-AnnualAnnual
yy yGenerator Testing and EvaluationMonthly TestAnnual TestILSM ( 45 Day Duration)ILSM Monitoring/ImplementationPlans for Improvement (PFI's)PFI #1PFI #2PFI #3yFacility ManagementFacility ManagementgN/AXXFacility Management4 (TJC only)Construction and Renovation Projects2agDescriptionDescriptionREDue DateStart DateStatusStatusILSM evalILSM EvalWebCident StatusIncident Reports1st Quarter2nd Quarter3rd Quarter4th QuarterCurrent Fiscal Year SummaryFY 2018PendingOpenCommentsILSM(s)(Y/N)PCRA 002nd Quarter1st Quarter3rd Quarter4th QuarterIncidents - Table and GraphsNo. ofIncidentsALL WORKER INCIDENTSPrevious Annual Summary1st Quarter2nd Quarter3rd Quarter4th QuarterCurrent Fiscal Year Summary0ALL WORKER INCIDENTSLOCATIONInside FacilityFY 20181st Quarter2nd Quarter3rd Quarter4th QuarterCurrent Fiscal Year SummaryFY 20182dPCRA (Y/N)Safety ManagementWebCident Status - Table and GraphPrevious Annual Summary2cILSM(s)(Y/N)Bloodborne ExposureBloodborne ExposuresFY 2018Previous Annual Summary1st Quarter2nd Quarter3rd Quarter4th QuarterCurrent Fiscal Year SummaryNo. of FTEsNo. ofIncidents/100 FTEs#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!On FacilityGrounds Off Premises(Outside)No. of Incidents/100 000.000.000.000.000.00Previous Annual Summary1st Quarter2nd Quarter3rd Quarter4th QuarterCurrent Fiscal Year SummaryWORKER INCIDENT BY LOCATION1.210.80.60.40.20001st Quarter0MucousNeedlesticks Total No. ofMembrane&SharpsBBPExposuresInjuriesExposures2nd QuarterInside Facility3rd QuarterOn Facility Grounds (Outside)4th QuarterOff PremisesBloodborne ExposuresMucous Membrane ExposuresNeedlesticks &Sharps Injuries10.80.60.40.200001st Quarter2nd Quarter3rd Quarter4th Quarter0Current Fiscal Year Summary
2eVISITOR INCIDENTSLOCATIONInside FacilityOn FacilityGrounds Off Premises(Outside)VISITOR INCIDENT BY LOCATION1.210.81st Quarter0.62nd QuarterFY 20180.40.23rd Quarter04th Quarter2fSECURITY INCIDENTSFY 20182g2h2iCurrent Fiscal Year Summary000TYPEAssault - PhysicalAssault - VerbalCivil DisturbanceDisorderly ConductControlled/Illegal SubstancesTheftThreat-VerbalControlled Access IncidentTampering -Facility Equipment1st QTR2nd QTR3rd QTRCurrent Fiscal Year Summary01st Quarter2nd QuarterInside Facility4th QTR3rd QuarterOn Facility Grounds (Outside)4th QuarterOff PremisesSecurity Issues FY 20181.21Assault - PhysicalAssault - Verbal0.8Civil DisturbanceDisorderly ConductControlled/Illegal Substances0.6TheftThreat-Verbal0.4Controlled Access IncidentTampering -Facility Equipment0.2Inpatient0Outpatient00In TransitERDepartmentPATIENT INCIDENTS-FALLSLOCATIONSFY 20181st Quarter2nd Quarter3rd Quarter4th QuarterCurrent Fiscal Year Summary0000PATIENT INCIDENTS-OTHERLOCATIONSInpatientOutpatientIn TransitFY 20181st Quarter2nd Quarter3rd Quarter4th QuarterCurrent Fiscal Year SummaryERDepartment02nd QTR1st QTR3rd QTR4th QTRPatient Incidents - Falls10.8Inpatient0.6Outpatient0.4In Transit0.20ER Department01st Quarter2nd Quarter3rd Quarter4th QuarterCurrent Fiscal Year SummaryPatient Incidents - Other10.8Inpatient0.6Outpatient0.4In Transit0.200000ER Department01st Quarter2nd Quarter3rd Quarter4th QuarterCurrent Fiscal Year SummaryMedication Error or Medication-Related Adverse Event- Table and GraphMedication Errors or Medication-related AdverseEventsFY 2018Webcident ReportsPrevious Annual Summary1st Quarter2nd Quarter3rd Quarter4th QuarterCurrent Fiscal Year SummaryCategory A/B Category CCategory Dor higher1000001st Quarter2nd QuarterCategory A/B3rd QuarterCategory CCategory D or higher4th Quarter0Current Fiscal Year Summary
Training and Competency Development - Table and Graph2jTraining and Competency DevelopmentDate of Completed Training(s)Total Number of AttendeesTopical AreaSee "Training Requirements"Tab for additional informationNumber ofAttendeesNo. ofRequiredAttendeesRespiratory ProtectionPortable Fire ExtinguishersBloodborne 0!#DIV/0!3aFirst Quarter SummaryAccomplishments, Sentinel Events, Critical Issues, and Challenges3bSecond Quarter SummaryAccomplishments, Sentinel Events, Critical Issues, and Challenges3cThird Quarter SummaryAccomplishments, Sentinel Events, Critical Issues, and Challenges3dFourth Quarter SummaryAccomplishments, Sentinel Events, Critical Issues, and ChallengesRequired Training Attendance iratoryProtectionPortable FireExtinguishersBloodbornePathogensFootnotes1 "Responsibility" of Staff for EC/LS/EM/Safety Management vary by Service Unit and health care facility.2 EOC meetings may be monthly, bimonthly, or quarterly3 "rel pressure" is relative pressure to adjacent areas. ACH is "Air Changes per Hour", calculated from supply or exhaust ventilation flowrates)4 Joint Commission requirement0.00.00.00.00.00.0Total
EOC - Facilities Management Department {Insert Facility Name} FY 2018CMSStandardJoint onthlyQuarterlySemi-AnnualAnnualX ACTION, RE )(2)§482.41(b)(8)§482.41(b)(8)LS.01.01.01 EP 2LS.01.01.01 EP 2LS.01.01.01 EP 3LS.01.01.01 EP EC.02.03.05 EP 1EC.02.03.05 EP 2EC.02.03.05 EP 2EC.02.03.05 EP 3EC.02.03.05 EP 4EC.02.03.05 EP 5EC.02.03.05 EP 6EC.02.03.05 EP 7EC.02.03.05 EP 8EC.02.03.05 EP 9EC.02.03.05 EP 10EC.02.03.05 EP 11EC.02.03.05 EP 12EC.02.03.05 EP 13EC.02.03.05 EP 14EC.02.03.05 EP 15EC.02.03.05 EP 41(c)(2)EC.02.03.05 EP 17EC.02.03.05 EP 18EC.02.03.05 EP 19EC.02.03.05 EP 20LS.01.02.01§482.41(b)(1)(i) LS.01.02.01 EP 3 ILSM policy developed and in placeCriteria for evaluating deficiencies & hazards to determine when and§482.41(b)(1)(i) LS.01.02.01 EP 3 to what extent ILSM measures apply§482.41(b)(1)(i) LS.01.02.01 EP 3 The organization implements ILSMs as defined in its 1(c)(2)Battery powered lights tested @ 30 days for 30 sec. andAnnually for 1.5 hrsStored Emerg. Pow. Sup. Sys. (SEPSS) for Life Safety tested 5 min.Annually @ full load for 60% of its class or rating for rechargeGenerators tested 12 X Yr cont. 30 min. under load that is at least30% of the nameplate rating Note: Alternate to load bank testallowed (must meet criteria) of maint. & inspection activities &EC.02.05.07 EPmonitor exhaust gas temp4,5EC.02.05.07 EP 6 Transfer switches 12 X YrEC.02.05.07 EP 7 Emergency generator test for a minimum of 4 continuous hoursXXEC.02.06.01 EP 13EC.02.06.01 EP 13EC.02.06.01 EP 13EC.02.06.01 EP MFMREREFMFMFMFMFMXFMXFMFMXXXX3YMedical Gas and Vacuum Systems are Inspected and TestedREEC.02.05.09 EP 1 Review maintenance program and testing documentationReview installation and modification of med gas test results for: crossEC.02.05.09 EP 2 connection, purity & pressureEC.02.05.09 EP 3 Med gas supply and zone valves are accessible and clearly 2.41(c)(4)§482.41(c)(4)REREREREXEmergency Power Systems are Maintained and TestedEC.02.05.07 EP 1EC.02.05.07 EP 2EC.02.05.07 EP 3EC.02.05.07 EP he facility establishes and maintains a safe, functional environment.Ventilation Testing (Isolation, OR)Ventilation Testing (CSR, Soiled Utility Rms)Ventilation Testing (Lab: Gen, Bact, Path.)Humidity Levels (test per policy)FMFMFMFMX3X3X3Footnotes1 Responsibility of Staff for Management Plans may vary by Service Unit and health care facility.2 Report only if Facilities Management is responsible for the function, otherwise it is N/A3 Recommend: Monthly test for relative pressure to adjacent areas. Annual Test for Air Changes per Hour, calculated from supply or exhaust ventilation VIEWType the following in the areas below: C (for complete), S (for scheduled), X (for incomplete) or N/ABuildings serving patients comply with NFPA 101 Life Safety Code (LSC) (2012 edition)FMCurrent Statement of Conditions (SOC) has been preparedReview Joint Commission or AAAHC equivalencies (if any)FMReview Plans for Improvement (PFI) check for timelinessFMSufficient progress toward PFIs in previous SOCFMAnnual Above the Ceiling InspectionFMFire Alarm Testing and InspectionSupervisory Signals (except tamper switches)Water flow devicesTamper switchesDuct, heat, smoke detectors, pull boxes, elect. releasing devicesNotification devices (audible & visual)Emergency services notification transmission equipmentFire pump(s) tested under no-load conditionsWater storage tank high & low level alarmsWater storage tank low water temp alarms (cold weather only)Sprinkler systems main drain tests on all risersFire department connections inspectedFire pump(s) tested annually underflowStandpipe systems tested with water flow (NFPA 25)Kitchen auto extinguishing systems inspected (no discharge reqd)Gaseous extinguishing systems inspected (no discharge reqd)Portable fire extinguishers inspected monthlyPortable fire extinguishers maintained annuallyAnnual Inventory Update for Fire EstinguishersFire hoses hydro tested 5 yrs after install, every 3 yrs afterSmoke & fire dampers tested (fusible links removed when applicable)Smoke detection shutdown devices for HVAC testedAll horizontal & vertical roller & slider doors tested5 Year NFPA Sprinker InspectionAnnual Sprinkler head InspectionAnnual Inventory Update for Sprinkler SystemInterim Life Safety Measures (ILSM)OCTX3X3X3
Accreditation Deficiency ItemsDef. No.DescriptionTotalProj. No.Cost (est)StatusCompletionDate (est)CommentsStatusCompletionDate (est)Comments Construction and Renovation ProjectsDescriptionCost (est) Total-Comments:Biomed PM's and Work OrdersWebTMA Implemtation Status:Facilities Management PM's and Work OrdersPreventative Maintenance (PM) and Work OrdersOCTNOVDECJANFEBMonthMAR APRMAYJUNJULAUGSEPCritical Equipment PM's - assignedCritical Equipment PM's - completedCritical Equipment PM's - completion %Critical Equipment PM's - goal##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### #####100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%Normal Equipment PM's - assignedNormal Equipment PM's - completedNormal Equipment PM's - completion %Normal Equipment PM's - goal##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### #####90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%No. of Work Orders AssignedNo. of Work Orders CompletedWork Orders Completion %##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### #####OCTNOVDECJANFEBMonthMAR APRMAYJUNJULAUGSEPCritical Equipment PM's - assignedCritical Equipment PM's - completedCritical Equipment PM's - completion %Critical Equipment PM's - goal##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### #####100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%Normal Equipment PM's - assignedNormal Equipment PM's - completedNormal Equipment PM's - completion %Normal Equipment PM's - goal##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### #####90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%No. of Work Orders AssignedNo. of Work Orders CompletedWork Orders Completion %##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### #####
Facilities Management PM'sBiomed PM'sCritical Equipment Completion Goal (100%)100%100%90%90%Normal Equipment Completion Goal 10%0%OCTNOVDECJANFEBMARAPRMAYJUNJULAUG0%SEP1234RS Vacant 6 months789Critical Equipment PM's - completion %Critical Equipment PM's - goalNormal Equipment PM's - completion %Normal Equipment PM's - goalNormal Equipment PM's - goalNormal Equipment PM's - goal#VALUE!Justification101112Budget InformationFunding AccountM&I (Bench Stock)M&I (Project Funded)FSA - SalariesFSA - UtilitiesQuartersMedical EquipmentTotals Current Year- Prior Year-Accomplishments, Sentinel Events, Critical Issues, and ChallengesFirst Quarter SummarySecond Quarter SummaryAccomplishments, Sentinel Events, Critical Issues, and ChallengesAccomplishments, Sentinel Events, Critical Issues, and Challengesrth Quarter SummaryAccomplishments, Sentinel Events, Critical Issues, and Challengesrd Quarter Summary6Critical Equipment PM's - goalQuarters Programuarters:uarters Occupied:Rate:5Critical Equipment PM's - completion %
Infection Preventionist's Reporting Dashboard - FY2018 forInfection Control Basic Program ElementsRequirementDescription and ResponsibilityWeeklyOCTMonthly Quarterlyemi-Annu AnnualDECJANFEBMARAPRMAYJUNJULAUGSEPANNUALREVIEWC COMPLETE; X MISSED, S SCHEDULED, N/A Not ApplicableX ACTION, RE REVIEW/EVALUATEInfection Control Committee MeetingNOVXInfection Prevention and Control Officer (IP&C Officer)Infection Control RoundsOutpatientClinical areas are completed semi-annuallyDepartmentalNonclinical departments are completed annuallyXCentral SterileClinical areas are completed semi-annuallyXDentalClinical areas are completed semi-annuallyXClinical LaboratoryClinical areas are completed semi-annuallyXXPlan ManagementIP&C Officer.XInfection Control Management PlanIP&C Officer.XInfection Control Risk AssessmentIP&C Officer. DO attached AMB Risk AssessmentXExposure Control PlanIP&C Officer.XTB Risk AssessmentIP&C Officer.XTB PlanIP&C Officer.XANNUAL SUMMARY (i.e., summary of risk-based goal results)Major Policies and ProceduresHigh-Level Disinfection and SterilizationHand HygieneExposure Incident ManagementRespiratory ProtectionAutoclave Cleaning and DisinfectionNosocomial Surveillance Policy(s)Patient InfluxCough Etiquette/Respiratory HygieneAntimicrobial UseDepartment: HousekeepingDepartment: MedicalDepartment: NursingDepartment: DentalDepartment: Laboratory Department: PharmacySurveillanceRequirementLaboratory Surveillanc e Data ReviewEmployee Tb Sc reeningDescription and ResponsibilityDailyWeekly Monthly Qtrly.SemiAnnualAnnualMandatory Reporting - Daily per IP&C OfficerREAnnually per Employee HealthREREALL Standard P rec autionsREMonitor Community Infec tious EventsHand HygieneMDROC. difficileICRA (required for any c onstruc tion projec ts, inc ludes c ableing)*For daily or weekly reviews: if a day or week is missed, indic ate with an "X " in the month where reviews are missing. RE annual evaluation SEPANNUALREVIEW
For daily or weekly reviews: if a day or week is missed, indic ate with an X in the month where reviews are missing. REDescriptionannual evaluation required.STI & Reportable DiseaseReportable Diseases TrackingCurrent Year1st QTR2nd QTR3rd QTRR EPOR TA B L E DI SEA SES TR A CKI N G4th QTRHep BHep CHep BHep CChlamydiaChlamydiaNeisseria GonorrheaNeisseria GonorrheaFY2018SyphilisSyphilis1 ST QTR2 ND QTR3 RD QTR4 TH QTREnvironmental ServicesDescriptionN U MB ER OF STER I L I ZATION FA I LU R ESSSterilization FailuresCY Qtr.% Sterilization FailuresCSR SterilizationFY2018# of SterilizationFailures# of SterilizationLoads% SterilizationFailures1st Quarter#DIV/0!2nd Quarter#DIV/0!3rd Quarter#DIV/0!4th Quarter#DIV/0!000#DIV/0!001 S
New Quality Framework to Guide Delivery of Care at IHS In 2016 the IHS Quality Framework developed to outline how the IHS will develop, implement, and sustain an effective quality program to: 1. Strengthen Organizational Capacity to Improve Quality of Care and Systems 2. Meet and Maintain Accreditation for IHS Direct Service Facilities 3.
