A Continuous Quality Improvement Program
Quarterly Report on Activities April 1-June 30, 2004
Strategic Plan– The Board approved the Strategic Plan including Mission, Vision, Value Statements, and Goals was passed on to the Leadership Team to develop short-term goals for their area. The Annual Report on activities for 2003-2004 were completed in October for review.
Review of Incidents, Accidents, and Grievances of Children- Safe Kids/Safe Staff
There were 94 incidents of restraint and 1 incident of seclusion this quarter. A managing supervisor who ensures that each child and staff involved is debriefed about the incident of restraint and scrutinizes all incidents. A quality assurance interview is also conducted to collect aggregate information, to report any training deviations, and to ensure that the child’s rights were not breached. The conclusion of the data collected for the grant concludes with June data. Beginning July 1, the data collection practices developed for the purposes of the grant are being streamlined to be both useful for program improvement and easy for the staff to maintain. The Clinical Director Staff will be able to continue to review and compare individual program information. A summary of total restraints by year are shown below:
Worker’s Compensation claims for the 2nd quarter 2004: 12 incidents of accidents in Macon and 9 incidents at other sites. This is an increase from last quarter of 10 in Macon and 6 at other sites. This is also an increase of 25% from same times last year in Macon. Incidents occurring in Columbus and Americus were about the same numbers as the same quarter last year. St.Marys had the 3 additional claims. That program was added within the year. In Macon, 33% of the injuries involving a restraint and 44% of injuries of other campuses were injuries during the physical restraint of a child. Training and supervision are specifically designed and provided for areas by this information.
Grievances for April, May, and June have been reviewed, prioritized in order of seriousness, and the Vice President of Programs has reviewed issues of highest priorities with each Regional Director.
Improvement Projects- The Staff Satisfaction Survey and report was completed and made available in May. The results of this survey have been shared with the IMPACT team so they can discuss the findings with their teams.
Utilization Review - The Utilization Review processes focus on appropriateness and effectiveness of client services, necessity of treatment, and cost-effectiveness of continued services to clients. Twenty-two files were reviewed, and twelve more are due to be reviewed by the date of this report for this quarter. Detailed findings are available in the Social Services Department. Findings for the file review are reported to the Family Consultants responsible and they remediate any problems or concerns by the time of the next scheduled Utilization Review.
Safety/Risk Management - The Risk Management Team met in February and April. The Risk Management Team consists of members of the Human Resources Department, Social Services Department, Health Services Department and the Peyton Assessment Center, as well as, a representative from each of our regional offices. The team meets bi-monthly to discuss various topics including known HIPPA violations and concerns, injuries to staff, safety concerns, maintenance concerns on campus and in the buildings, and the updating of First Aid kits and Disaster Preparedness kits.
The Risk Management Team completes inspections of the buildings on a bi-monthly basis. During this inspection they look for safety violations, as well as, maintenance requirements. This is done to limit the liability of the agency and to make sure we are compliant with state licensing requirements as well as safety requirements of the worker’s compensation carrier. The team looks for mandatory postings of the WC-P3 (pink worker’s compensation) form and the access to Material Safety Data Sheets. The risk management team also reviews the worker’s compensation claims with the express purpose of making resolutions/corrections to prevent additional accidents. Three living units were reviewed this quarter.
• The MATCH Outcome Process (MOP) Consumer Satisfaction Survey continues to be compiled for all children discharged from January 1-June 30, 2004 and the results will be returned to the State Office.
• The Council on Accreditation (COA) Self Study was completed and delivered to New York Offices the first week in July 2004. The site visit is scheduled for September 27, 2004. Thanks to Robin Riley who took over as lead coordinator of this project in February of this year.
ITEM REQUIRING STAFF ATTENTION:
1) Complete respective policy and procedure changes for Methodist Home Policy and Procedure Manual revisions, due complete September 1st.
2) Complete the short term plan within the Strategic Plan Goals
3) Leadership Team and Program Directors to complete the Annual Report for their departments and programs.
4) Continue to contribute meaningfully in the IMPACT meeting by completing surveys, developing remediation plans, and attending meetings.
ITEMS REQUIRING BOARD ATTENTION:
1) COA On-site visit is the week of September 20, 2004
2) Endorsement of the Strategic Plan
Respectfully submitted,
Jill Chambers Myers, MPA
Director of IMPACT
Evaluator, Safe Kids/Safe Staff
jill.myers@themethodisthome.org |
