EOC Assessment & Compliance Tool Vonda Broom, Deputy Director EPS (10NA7) Comprehensive Environment of Care (CEOC) Program Q1 and Q2 FY16 - Overview

EOC Assessment & Compliance Tool Vonda Broom, Deputy Director EPS (10NA7) Comprehensive Environment of Care (CEOC) Program Q1 and Q2 FY16 - Overview

Environment Of Care (EOC) Assessment & Compliance Tool Status Update Q2 FY2016 More than 10,000 staff have been briefed and trained Over 100 on-site and 350 webinars training sessions held In Q1 and Q2 FY2016 Inspection Data 5,500+ inspections completed Over 60,000 deficiencies cited Over 14,000 citations on the Environmental Management checklist Average number of days to close out EOC deficiencies: Q1 FY2015 through Q2 FY2016: from 28.4 days to 10.4 days 63.4% improvement in days to close out deficiencies Percent of deficiencies addressed within 14 business days 89.4% completed or with a plan for action added 1

Inspections and Deficiencies (Q1 FY2015-Q2 FY2016) 40,000 Total Inspections Conducted and Deficiencies Cited 35,000 30,000 30,099 32,160 34,237 31,672 28,926 32,650 25,000 20,000 15,000 10,000 5,000 2,661 2,804 3,060 2,934 2,665 2,865 0 Q1 '15 Q2 '15 Q3 '15 Q4 '15 Q1 '16 Q2 '16 Inspections Deficiences 2

Inspections and Deficiencies (Q1 & Q2 FY2016) Completed Inspections Total Deficiencies Q1 FY 2016 2,665 28,926 Q2 FY 2016 2,865 32,650 Total 5,530 61,576 14,000 12,000 10,000 10,878 Total Inspections Conducted and Deficiencies Cited 9,087 8,961 10,097 10,304 12,249 8,000 6,000 4,000 2,000 992 816 857 866 914 1,085 0 Oct '15 Nov '15 Dec '15 Jan '16 Feb '16 Mar '16 Inspections Deficiences 3

Percent of Deficiencies Addressed within 14 Business Days (Q1 & Q2 FY2016) Total Deficiencies EPS Deficiencies Overall % Completed within 14 Days EPS % Completed within 14 Days Q1 FY 2016 28,926 6,617 77.2% 82.9% Q2 FY 2016 32,650 7,396 79.2% 83.0% Total 61,576 14,013 78.3% 82.9% E5EOC1 Deficiencies identified during EOC rounds are closed within 14- business days or have a documented Plan for Action (PFA) 85% of deficiencies within each quarter are closed or have a PFA within 14- business days 90% of deficiencies within each quarter are closed or have a PFA within 14- business days 95% of deficiencies within each quarter are closed of have a PFA within 14- business days 4

Percent of Deficiencies Addressed within 14 Business Days (Q1 & Q2 FY2016) 100.0% Percent of Deficiencies Addressed within 14 Business Days 90.0% 80.0% 81.7% 81.7% 78.0% 76.8% 85.3% 82.3% 83.8% 84.3% 78.3% 78.8% 79.1% 79.6% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Oct '15 Nov '15 Dec '15 Jan '16 Feb '16 Mar '16 Overall EMS 5

Average Time to Close Out Deficiencies (Q1 & Q2 FY2016) 20 Average Days to Completion 18 16.7 17.8 16 15.6 14 12 13.8 14.1 12.4 12.1 12.0 10.8 10 8 9.3 8.6 8.2 6 4 2 0 Oct '15 Nov '15 Dec '15 Jan '16 Feb '16 Mar '16 All Checklists EMS Checklist 6

Rounds Attendance E5EOC2 A member of the Senior Management Team or their Acting designee attends EOC rounds on a regular basis 85% of EOC rounds within fiscal year are attended by a Senior Leader 90% of EOC rounds within fiscal year are attended by a Senior Leader 95% of EOC rounds within fiscal year are attended by a Senior Leader E5EOC5 Facility EOC rounds team members participate in weekly rounds 85% participation in weekly EOC rounds over the fiscal year 90% participation in weekly EOC rounds over the fiscal year 95% participation in weekly EOC rounds over the fiscal year 7

Rounds Attendance (Q1 FY2015-Q2 FY2016) 100.0% Percent Attended on Rounds 90.0% 80.0% 70.0% 68.6% 71.6% 79.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Overall Attendance Senior Leadership EMS 8

Rounds Attendance (Q1 FY2015-Q2 FY2016) 100.0% 90.0% 80.0% 70.0% 60.0% 69.2% 74.0% 81.3% 75.2% 70.5% EMS Percent Attended on Rounds 75.5% 76.0% 59.9% 86.7% 81.6% 86.3% 92.0% 77.2% 86.4% 84.8% 80.5% 81.8% 74.7% 87.8% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 1 2 4 5 6 7 8 9 10 12 15 16 17 18 19 20 21 22 23 9

Top Deficiencies Across Checklists (Q1 & Q2 FY2016) 10

Top Cited EMS Related Deficiencies (Q1 & Q2 FY2016) 11

Helpful Hints Troubleshooting and Support is available from Performance Logic Monday-Friday, 9:00am-8:00pm ET 888-407-1705x2 support@performancelogic.com Mobile Devices: Fujitsu Device ipad Device The Tablet application can also be loaded on the desktop computer of inspectors to input deficiencies after rounds 12

Helpful Hints CEOSH Webpage EOC Tool Landing Page http://vaww.ceosh.med.va.gov/10n/10na7-eps/pages/eocrounds.shtml 13

News EOC Governance Changes Use of alternative mobile devices Published VHA Directive 1608 Comprehensive Environment of Care (CEOC) Program Network Director Performance Measures Closeout of deficiencies Attendance Tracking How data is used at the national level Who has access to this data? Transition to Azure Cloud 14

Questions 15