PI BASICS
Performance Improvement (PI):
- is required & evaluated by the Joint Commission (JC)
- parallels & complements JC’s standards (i.e., PI, Information Management, EOC, Leadership)
- is a continuous, planned, systematic, interdisciplinary, organization wide process
- involves measuring the functioning of important processes & services (treatment, care, services, safety)
- identifies changes that enhance performance, outcomes & safety
- monitors performance to ensure that improvements are sustained
- is directed & supported by agency leadership & governance
Fundamental & integrated components of PI:
- Monitoring & measuring performance through data collection, analysis & interpretation
- Assessing current performance (using current & comparative longitudinal & aggregated data)
- Improving performance & maintaining improvements – early problem detection/correction &/or improvement in non-problematic processes (e.g., efficiency, effectiveness)
THE HILLCREST PI PROGRAM
Hillcrest’s PI structure:
1) Campus specific interdisciplinary IOP Committee – meets monthly, provides quarterly reports
2) Management Team
3) Policy & Operations Group
4) BOD Quality Assurance Subcommittee & BOD
Hillcrest’s PI program consists of 2 components:
1) Campus specific, short or long term IOP performance measures
(e.g., HP measures/analyzes sexual incidents)
2) Agency-wide IOP performance measures:
- Student Injuries During Restraints
- Staff Injuries During Restraints
- Physical Interventions
- Medication Errors & Adverse Drug Reaction
- Student Perception of Care
- PRN usage
- Exposures to infection/communicable disease
- Timeliness of documentation
- Environment of Care (e.g., safety, security, injuries, utility management, hazard surveillance, emergency preparedness, fire & evacuation drills)
- Incidents/incident reports
- General improvements
Agency-wide IOP performance measures a) thru e): Details
a) Student Injuries During Restraints (All Campuses)
The number of student injuries that occur during restraints, for the month and for the quarter (as documented on Incident Report and Physical Incident Report forms).
Administration cycle: ongoing
b) Staff Injuries During Restraints (All Campuses)
For the month and the quarter, all staff injuries:
- that occur during restraints;
- and for which ART forms are completed
Administration cycle: ongoing
c) Physical Interventions (All Campuses)
For the month and the quarter, the number of:
- Restraints
- Extended Restraints
- Total Restraints.
Administration cycle: ongoing
d) Medication Errors & Adverse Drug Reactions (All Campuses)
The following medication errors are tracked:
- wrong medications (a medication not prescribed by a physician).
- wrong dosages (for medication prescribed by a physician, a dosage not prescribed by a physician is administered; higher or lower than prescribed).
- omissions/missed medications (medications prescribed by a physician but not administered).
- Adverse reactions to medications
Administration cycle: ongoing
e) Student Perception of Care (All Campuses)
Average “cluster scores” for each of 7 subsections on the HEC CS Survey:
- Environment of Care
- School/Education
- Medical/Dental
- Staff
- Treatment
- Program
plus an average of the total ratings for survey. Scores reported by campus and in aggregate form for the agency. The PM consists of the averaged scores themselves (cluster scores and survey total score; campus + agency), and the differences between (+/-) the current quarter and those of the last quarter and the previous year.
Administration cycle: annual for all students (90 or more days after admission & w/in 6 months of discharge)
The Reporting cycle & content for all PMs: Quarterly
For Quarterly data, comparisons with the previous Quarter of the current year, and the same Quarter in the previous year.