2009 Quality Planning Program:

Transcription

1 2009 Quality Planning Program: Reference: Business Risk Management Plan & Strategic Planning Links to MOH Improving Quality Plan / ACC Work Safe Management Practices Meetings Schedule: CQI / Staff Meetings: Previous months stats [ exceptions ] discussed Monthly Resident Meetings / Morning Tea Monthly Service Analysis & Ongoing Planning Service Review Meeting [Annual Review].. Feb 09 Service Review Meeting [1st Review]. May 09 Service Review Meeting [2nd Review]. Aug 09 Service Review Meeting [3 rd Review]. Nov 09 Service Review Meetings Agenda Items for Discussion o Review of Exception Reports: Concerns, complaints Staff Injury Resident Falls & Skin Tears Medication Errors Resident Infections Challenging Behaviours Needle stick injuries / hazardous waste incidents Hospital Admissions o Occupancy Enquiry, Exits & Transfers o Review of Service Objectives o Review of Hazards o Education Program o Staffing Levels & Ethnicity Planning o Results of Audits o Emergency Readiness o Appropriateness of Data Collection & Documentation o HR & Employment issues o Staff Participation o Planned Purchases o Contractor competence o General Discussion Quality Planning: Quality Review Infection Control Program. 09 Quality Review Medicine Management Program. 09 Quality Review Restraints. 09 Quality Review Social Program Seeking Continuous Quality Improvement Page 1 of 7

2 2009 Quality Planning Program: Suggested Audit Calendar Crossed off as they are completed. Audit Jan Feb Mar April May June July Aug Sept Oct Nov Dec Care Planning Informed Consent Satisfaction Complaints Kitchen Laundry Housekeeping Single Use Items Call Bells Survey Back Pain Hand Washing Survey Personal Cares Audit Menu Self Assessment Norovirus Preparedness Business Management Plan Strategic Planning Health & Safety Management System Annual Audit For those in WSMP Reference: Internal Audit Work Book Seeking Continuous Quality Improvement Page 2 of 7

3 2009 Quality Planning Program: We are active members of the Healthcare help Benchmarking Stats Program: [Identifying Opportunities for Improvement and minimising preventable harm]. Nationwide program that compares our exceptions [falls, medication errors, infections, challenging behaviours, hospital admissions, more] with the AVERAGE of other similar providers in New Zealand. Hospitals compared to hospitals, Rest Homes compared to Rest Homes, Hospices compared to Hospices]. Method: 1. By counting things that go wrong [falls / infections / etc] [Data entered online] 2. By counting them accurately [According to agreed criteria available online] 3. By comparing them by rate rather than by number [Further accuracy, as below] 4. By comparing rates to globally agreed acceptable rates [Threshold Values] 5. By excluding those that we need not count [Exclusions available online] 6. By recognising early when we need to improve [Coloured printouts for staff] 7. Seeking Continuous Improvement [Online program links to Help Pages ] Accuracy: To accurately compare different sized Homes / Services we need to make a rate. This is the formula: Numerator = Number of falls for the month x Denominator = Bed days occupied Example: Falls in April, 2009 = 3 x beds occupied for all 30 days in the month = or 3000 divided by Benchmarking Stats Example: FALLS RATE Compared to AVERAGE of everyone else 1. ENTER BED DAYS 2. ENTER FALLS [with fracture] [harmed] [unharmed] [total falls] Seeking Continuous Quality Improvement Page 3 of 7

4 2009 Quality Planning Program How it Works Falls Infections Medication Problems Challenging Behaviours Hospital Admissions Input numbers to the Web Site Website collates the data automatically Number X 1000 Occupied bed days x 1000 Needle stick Injuries & other Assistance IDENTIFY HELP IS NEEDED More Help so we can PREVENT happening again Print out Coloured Graphs These compare our figures with: - Average of everyone else - threshold Values e.g falls per 1000 occupied bed days [easily see if we are OVER] Review Continue to monitor Meets the threshold OK Issued: Seeking Continuous Quality Improvement Page 4 of 7

5 2009 Quality Planning Program: Example Falls Report prepared for the Staff Meeting 2008 using Healthcare Help Benchmarking Stats 7 6 Aim to stay Under threshold Falls are well above the threshold value in January & April with more than 5 falls each of these months: - Short Term Care Planning for our High Risk Fallers individualised for anyone who had fallen introduced early May. - This has helped us be fully aware of the huge extra effort required to keep our at risk residents safe. - Thank you and well done everyone considering how frail, yet mobile, most of our residents are. - Every fall risks broken hip. Lets reduce the opportunities: know toileting regimes / use our sensor mats / more Reference: Link to Help Improve Stats for guidelines to Falls Prevention Program. Note: Benchmarking Stats allow us to right click & copy to download our own graphs and paste into reports. Issued: Seeking Continuous Quality Improvement Page 5 of 7

6 2009 Quality Planning Program: Exception Reporting Forms collect data in the following categories: Medication Errors Falls Infection Rates Challenging Behaviours Hosp Admission Pressure Ulcers Given but not signed for Incorrect Drug Incorrect Dose Incorrect Resident Unharmed Hurt With broken bone UTI Chest [LRTI] Flu Cold Diarrhoeal Hitting / Striking Out Verbal Outburst/ Yelling Whereabouts unknown Admission RE-Admit within 30 days of discharge Threshold Value = 0 Exclude if admitted with pressure ulcer. Incorrect Time Administration Error Adverse Reaction Refusal Dispensing Error Missed Med Prescribing Error Total Falls Skin & wound Eye / Ear Norovirus MRSA VRE ESBL Scabies Repeat Behaviours Requests for help beyond scope of Service Inappropriate touching or suggestions or comments including racist remarks Tuberculosis Issued: Seeking Continuous Quality Improvement Page 6 of 7

7 Training Needs: Continue with External Training: Ace Training Basic / Ace training Dementia Approved External Trainers Career force Training Healthcare Help Free online Training Modules Education in response to exception reports: Timely follow up after something has gone wrong Continuing work in Falls Prevention [reviewing each high risk faller and ensuring preventative measures well known to staff. Staff please request training in areas where you feel you need extra knowledge / support / where residents have new or complicated comorbidities/ where mistakes are happening. Gerontology Nurse Specialists are now coming out to the Home and giving practical support: Attend relevant DHB training as it is offered Look for and upgrade to new guidelines [e.g. menu planning for diabetics & new Cardio Vascular Disease Guideline] 2009 Quality Planning: Staff Traini ng Healthcare Help Resources for 2009 Inhouse Program: - H&S Induction Training / declarations / - Module 1 [Code of Rights privacy & Dignity Consent & Informed Consent] - Module 2 [Fire warden & Emergency Planning] - Module 3 [Safe Prescribing for RN & Manager especially] - Module 4 [Safe Medication Administration] - Module 5 [Diabetes & Insulin Admin] - Module 6 [Controlled Drugs] - Module 7 [ Challenging Behaviour] - Module 8 [Restraint Minimisation] - Module 9 [Moving & Handling] - Module 10 [Prevention of Abuse & Neglect] - Module 11 [Infection Control] - Module 12 [Death & Dying / Comfort Cares] - Module 13 [Reducing Falls / Continence Management. Issued: Seeking Continuous Quality Improvement Page 7 of 7